Provider Demographics
NPI:1528537529
Name:GONG, JOHN YOUNG (PHARM D)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:YOUNG
Last Name:GONG
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 VALLEY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2957
Mailing Address - Country:US
Mailing Address - Phone:310-372-7470
Mailing Address - Fax:
Practice Address - Street 1:1809 VERDUGO BLVD STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1402
Practice Address - Country:US
Practice Address - Phone:819-928-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist