MEDICARE: GORDON WONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PHY36924	CA

General Provider Information

NPI Number	:	1710987433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON WONG

Provider Business Mailing Address
First Line	:	16630 MARQUEZ AVE
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3233
Country	:	US
Telephone Number	:	310-454-6000
Fax Number	:	310-454-0605

Provider Business Practice Location Address
First Line	:	16630 MARQUEZ AVE
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3233
Country	:	US
Telephone Number	:	310-454-6000
Fax Number	:	310-454-0605

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	07/08/2007

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Directions to “ GORDON WONG ” Practice Location

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