Provider Demographics
NPI:1114207271
Name:WONG, CLIFFORD CHAN (PHARM BS)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:CHAN
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARM BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LOS GATOS CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3422
Mailing Address - Country:US
Mailing Address - Phone:916-391-5179
Mailing Address - Fax:
Practice Address - Street 1:6 LOS GATOS CIR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3422
Practice Address - Country:US
Practice Address - Phone:916-391-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH29961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist