Provider Demographics
NPI:1912061292
Name:FONG, WYMAN (RPH)
Entity Type:Individual
Prefix:
First Name:WYMAN
Middle Name:
Last Name:FONG
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 1:1952 LARKIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-2619
Mailing Address - Country:US
Mailing Address - Phone:510-235-4443
Mailing Address - Fax:510-235-5527
Practice Address - Street 1:1952 LARKIN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-2619
Practice Address - Country:US
Practice Address - Phone:510-235-4443
Practice Address - Fax:510-235-5527
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist