Provider Demographics
NPI:1174689715
Name:LOUIS & MARY JO WONG
Entity type:Organization
Organization Name:LOUIS & MARY JO WONG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:TAI WAI
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:213-483-5910
Mailing Address - Street 1:2200 W 3RD ST STE 390
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1932
Mailing Address - Country:US
Mailing Address - Phone:213-483-5910
Mailing Address - Fax:213-483-5913
Practice Address - Street 1:2200 W 3RD ST STE 390
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1932
Practice Address - Country:US
Practice Address - Phone:213-483-5910
Practice Address - Fax:213-483-5913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02889620001332B00000X
332B00000X, 3336C0003X
CAPHY307613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA307610Medicaid
CAPHY58007Medicaid
CA1174689715Medicaid