Provider Demographics
NPI:1659347938
Name:WONG, SHANNON L (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:WONG
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 1:2817 E VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-5327
Mailing Address - Country:US
Mailing Address - Phone:559-353-5052
Mailing Address - Fax:559-353-8180
Practice Address - Street 1:9300 VALLEY CHILDRENS PLACE
Practice Address - Street 2:CHARLIE MITCHELL CHILDRENS CLINIC MB01
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-3227
Practice Address - Country:US
Practice Address - Phone:559-353-5052
Practice Address - Fax:559-353-8180
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist