Provider Demographics
NPI:1780604439
Name:WONG, WESLEY RANDALL (RPH)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:RANDALL
Last Name:WONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8337 TELEGRAPH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4931
Mailing Address - Country:US
Mailing Address - Phone:562-806-2239
Mailing Address - Fax:562-806-2500
Practice Address - Street 1:8337 TELEGRAPH RD STE 101
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4931
Practice Address - Country:US
Practice Address - Phone:562-806-2239
Practice Address - Fax:562-806-2500
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA292270Medicare ID - Type UnspecifiedPHARMACEUTICALS