Basic Information
| Provider Information | |||||||||
| NPI: | 1891243671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONG | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | WAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19048 SHAKESPEARE DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917894239 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5TH STREET & WESTERN | ||||||||
| Address2: | |||||||||
| City: | NORCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928600991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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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 | 60275 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.