Provider Demographics
NPI:1891157830
Name:WONG, BONNIE MICHELLE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:MICHELLE
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 S PALM AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2928
Mailing Address - Country:US
Mailing Address - Phone:925-872-5385
Mailing Address - Fax:
Practice Address - Street 1:2825 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6039
Practice Address - Country:US
Practice Address - Phone:916-887-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist