Provider Demographics
NPI:1952958811
Name:WONG, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:3055 W FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-3617
Mailing Address - Country:US
Mailing Address - Phone:951-652-0866
Mailing Address - Fax:
Practice Address - Street 1:3055 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3617
Practice Address - Country:US
Practice Address - Phone:951-652-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78104333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy