=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659347938
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON L WONG PHARM D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2006
-----------------------------------------------------
Last Update Date | 08/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 VALLEY CHILDRENS PLACE CHARLIE MITCHELL CHILDRENS CLINIC MB01
-----------------------------------------------------
City | MADERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93636-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-353-5052
-----------------------------------------------------
Fax | 559-353-8180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2817 E VERMONT AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-5327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-353-5052
-----------------------------------------------------
Fax | 559-353-8180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 48897
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------