Provider Demographics
NPI:1710987433
Name:WONG, GORDON
Entity Type:Individual
Prefix:
First Name:GORDON
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 1:16630 MARQUEZ AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3233
Mailing Address - Country:US
Mailing Address - Phone:310-454-6000
Mailing Address - Fax:310-454-0605
Practice Address - Street 1:16630 MARQUEZ AVE
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3233
Practice Address - Country:US
Practice Address - Phone:310-454-6000
Practice Address - Fax:310-454-0605
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY36924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist