Provider Demographics
NPI:1932580974
Name:WONG, GAVIN (PHARMCIST)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMCIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 E ONTARIO AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3600
Mailing Address - Country:US
Mailing Address - Phone:951-734-9765
Mailing Address - Fax:
Practice Address - Street 1:1260 E ONTARIO AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3600
Practice Address - Country:US
Practice Address - Phone:951-734-9765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist