Provider Demographics
NPI:1801559471
Name:KONG, EDMUND (PHARMD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:KONG
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 1:15367 FARNSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-2040
Mailing Address - Country:US
Mailing Address - Phone:510-508-1119
Mailing Address - Fax:
Practice Address - Street 1:7299 LAGUNA BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5059
Practice Address - Country:US
Practice Address - Phone:916-691-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85417183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist