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General NPI Number Information
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NPI Number | 1275881237
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Entity Type | Individual
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Provider Name | KEVIN WONG
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Gender | Male
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Dates
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Enumeration Date | 08/23/2012
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Last Update Date | 11/07/2015
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Provider Practice Location Address
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Address Line | 2089 PHEASANT DR
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City | HERCULES
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State | CA
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Zip | 94547-1627
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Country | US
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Telephone | 510-799-2288
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Fax |
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Provider Business Mailing Address
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Address Line | 999 LAKE DR
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City | ISSAQUAH
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State | WA
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Zip | 98027-8990
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 67355
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License Number State | CA
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