Provider Demographics
NPI:1134674039
Name:WONG, BRANDON (RPH)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 CABALLISTA DEL SUR
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3446
Mailing Address - Country:US
Mailing Address - Phone:949-361-1006
Mailing Address - Fax:
Practice Address - Street 1:25622 CROWN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-0464
Practice Address - Country:US
Practice Address - Phone:949-347-6751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist