Provider Demographics
NPI:1992091847
Name:KONG, SU JIAN (PHARMD)
Entity type:Individual
Prefix:
First Name:SU JIAN
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SU JIAN
Other - Middle Name:
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1751 UNIVERSITY DR
Mailing Address - Street 2:T1040
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-7775
Mailing Address - Country:US
Mailing Address - Phone:760-208-6000
Mailing Address - Fax:
Practice Address - Street 1:1751 UNIVERSITY DR
Practice Address - Street 2:T1040
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-7775
Practice Address - Country:US
Practice Address - Phone:760-208-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist