Provider Demographics
NPI:1376160531
Name:WONG, BRIAN RANDALL
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:RANDALL
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 1:4379 TERRABELLA PL
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-3161
Mailing Address - Country:US
Mailing Address - Phone:925-408-3566
Mailing Address - Fax:
Practice Address - Street 1:470 N AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-9701
Practice Address - Country:US
Practice Address - Phone:530-934-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist