Provider Demographics
NPI:1821327206
Name:GONG, DIANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 S GESSNER RD
Mailing Address - Street 2:APT 382
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-2044
Mailing Address - Country:US
Mailing Address - Phone:415-420-8533
Mailing Address - Fax:
Practice Address - Street 1:2401 S GESSNER RD
Practice Address - Street 2:APT 382
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-2044
Practice Address - Country:US
Practice Address - Phone:415-420-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist