Provider Demographics
NPI:1255749222
Name:WONG, MATTHEW DOC MING
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DOC MING
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 TWIN CITIES RD
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-9032
Mailing Address - Country:US
Mailing Address - Phone:209-744-1965
Mailing Address - Fax:
Practice Address - Street 1:10470 TWIN CITIES RD
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-9032
Practice Address - Country:US
Practice Address - Phone:209-744-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist