Provider Demographics
NPI:1568782704
Name:TONG, SHANNEN HUONG
Entity Type:Individual
Prefix:
First Name:SHANNEN
Middle Name:HUONG
Last Name:TONG
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 1:15584 FAITH ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5739
Mailing Address - Country:US
Mailing Address - Phone:909-829-3848
Mailing Address - Fax:
Practice Address - Street 1:11673 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-0141
Practice Address - Country:US
Practice Address - Phone:909-357-2031
Practice Address - Fax:909-357-1620
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist