Healthcare Provider Details

I. General information

NPI: 1568515781
Provider Name (Legal Business Name): GORDON JIN WONG R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL ROAD
PORTLAND OR
97239
US

IV. Provider business mailing address

4075 SW 107TH AVE APT 13
BEAVERTON OR
97005-3255
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 503-646-5576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number36389
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: