Provider Demographics
NPI:1194804864
Name:STEPHEN SHING WONG
Entity type:Organization
Organization Name:STEPHEN SHING WONG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-428-7500
Mailing Address - Street 1:4600 47TH AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95824-3923
Mailing Address - Country:US
Mailing Address - Phone:916-428-7500
Mailing Address - Fax:916-421-0506
Practice Address - Street 1:4600 47TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824-3923
Practice Address - Country:US
Practice Address - Phone:916-428-7500
Practice Address - Fax:916-421-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY405903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA405900Medicaid
2082997OtherPK