Provider Demographics
NPI:1922361112
Name:KONG, JEAN (RPH)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 E HERNDON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2993
Mailing Address - Country:US
Mailing Address - Phone:559-438-2888
Mailing Address - Fax:559-438-0711
Practice Address - Street 1:540 E HERNDON AVE STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2993
Practice Address - Country:US
Practice Address - Phone:559-438-2888
Practice Address - Fax:559-438-0711
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 58386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist