Basic Information
| Provider Information | |||||||||
| NPI: | 1801166053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONG | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 77 | ||||||||
| Address2: | |||||||||
| City: | SAN QUENTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949640077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507556132 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SAN QUENTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949641000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154541460 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2012 | ||||||||
| LastUpdateDate: | 09/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH46304 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.