Provider Demographics
NPI:1659670537
Name:WONG, EDLEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EDLEN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 SHADELANDS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2522
Mailing Address - Country:US
Mailing Address - Phone:925-979-6856
Mailing Address - Fax:
Practice Address - Street 1:2880 SHADELANDS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2522
Practice Address - Country:US
Practice Address - Phone:925-979-6856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist