Provider Demographics
NPI:1366062317
Name:HONG, KEVIN Q
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:Q
Last Name:HONG
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 1:740 BIG DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-1917
Mailing Address - Country:US
Mailing Address - Phone:626-482-4605
Mailing Address - Fax:
Practice Address - Street 1:949 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4119
Practice Address - Country:US
Practice Address - Phone:707-262-0244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist