Provider Demographics
NPI:1316640907
Name:JUNG, ALEXANDER GONG (RPH)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:GONG
Last Name:JUNG
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 1:1323 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2149
Mailing Address - Country:US
Mailing Address - Phone:209-981-2126
Mailing Address - Fax:
Practice Address - Street 1:471 3RD ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3576
Practice Address - Country:US
Practice Address - Phone:415-454-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist