Provider Demographics
NPI:1538638531
Name:GONG, SAMUEL JOHN (PHARM D)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOHN
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 1:2106 YOSEMITE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-2702
Mailing Address - Country:US
Mailing Address - Phone:310-780-0735
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:818-928-1304
Practice Address - Fax:818-928-1305
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
CA73202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist