Provider Demographics
NPI:1548772551
Name:WANG, FONGCHUN
Entity Type:Individual
Prefix:
First Name:FONGCHUN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S PARK VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5724
Mailing Address - Country:US
Mailing Address - Phone:408-262-2056
Mailing Address - Fax:
Practice Address - Street 1:114 S PARK VICTORIA DR
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-5724
Practice Address - Country:US
Practice Address - Phone:408-262-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist