Provider Demographics
NPI:1558897793
Name:WONG, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PULLMAN ST
Mailing Address - Street 2:BUILDING G, 2ND FLOOR
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-9756
Mailing Address - Country:US
Mailing Address - Phone:925-294-7661
Mailing Address - Fax:
Practice Address - Street 1:300 PULLMAN ST
Practice Address - Street 2:BUILDING G, 2ND FLOOR
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-9756
Practice Address - Country:US
Practice Address - Phone:925-294-7661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist