Provider Demographics
NPI:1184031114
Name:LEONG, BEN
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:LEONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 WATERFALL ISLE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5647
Mailing Address - Country:US
Mailing Address - Phone:510-566-8828
Mailing Address - Fax:
Practice Address - Street 1:639 WATERFALL ISLE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5647
Practice Address - Country:US
Practice Address - Phone:510-566-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist