Provider Demographics
NPI:1740612670
Name:CONG, JASEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:
Last Name:CONG
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 1:117 E LIVE OAK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5269
Mailing Address - Country:US
Mailing Address - Phone:509-247-2222
Mailing Address - Fax:
Practice Address - Street 1:117 E LIVE OAK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5269
Practice Address - Country:US
Practice Address - Phone:509-247-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60373244183500000X
CA70549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist