Provider Demographics
NPI:1720514300
Name:WONG, BRIAN (PHARMD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 E SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6752
Mailing Address - Country:US
Mailing Address - Phone:559-224-2965
Mailing Address - Fax:
Practice Address - Street 1:3011 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6752
Practice Address - Country:US
Practice Address - Phone:559-224-2965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71869183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist