Provider Demographics
NPI:1679048524
Name:KONG, RICKY PHAL (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:PHAL
Last Name:KONG
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 1:1 WATER GARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6663
Mailing Address - Country:US
Mailing Address - Phone:252-903-0198
Mailing Address - Fax:
Practice Address - Street 1:1020 BRADFORD PLAZA WAY
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-9230
Practice Address - Country:US
Practice Address - Phone:919-460-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist