Provider Demographics
NPI:1134256704
Name:WONG, RAYMOND (PHARMD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:WONG
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 1:1850 S AZUSA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6813
Mailing Address - Country:US
Mailing Address - Phone:626-912-3311
Mailing Address - Fax:626-912-3221
Practice Address - Street 1:1850 S AZUSA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6813
Practice Address - Country:US
Practice Address - Phone:626-912-3311
Practice Address - Fax:626-912-3221
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY35041332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA350410Medicaid