Provider Demographics
NPI:1386024867
Name:WONG, DOUGLAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
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 1:9831 CAMPO RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1418
Mailing Address - Country:US
Mailing Address - Phone:619-461-9170
Mailing Address - Fax:619-461-6735
Practice Address - Street 1:9831 CAMPO RD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-1418
Practice Address - Country:US
Practice Address - Phone:619-461-9170
Practice Address - Fax:619-461-6735
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist