Provider Demographics
NPI:1891243671
Name:KONG, PHILIP WAH
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:WAH
Last Name:KONG
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 1:19048 SHAKESPEARE DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5TH STREET & WESTERN
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-0991
Practice Address - Country:US
Practice Address - Phone:951-737-2683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60275183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist