Provider Demographics
NPI:1497800825
Name:SHUMWONG CORPORATION
Entity Type:Organization
Organization Name:SHUMWONG CORPORATION
Other - Org Name:SYCAMORE MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RPH
Authorized Official - Phone:925-682-5600
Mailing Address - Street 1:2485 HIGH SCHOOL AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1819
Mailing Address - Country:US
Mailing Address - Phone:925-682-5600
Mailing Address - Fax:925-682-0609
Practice Address - Street 1:2485 HIGH SCHOOL AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1819
Practice Address - Country:US
Practice Address - Phone:925-682-5600
Practice Address - Fax:925-682-0609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY309743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0550916OtherNCPDP
CAPHY30874OtherPHARMACY PERMIT
CAPHA308740Medicaid
CAPHA308740Medicaid