Provider Demographics
NPI:1366219628
Name:LIONG, EDRIC MERVYN
Entity type:Individual
Prefix:
First Name:EDRIC MERVYN
Middle Name:
Last Name:LIONG
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 1:5554 HAVENCREST CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7178
Mailing Address - Country:US
Mailing Address - Phone:209-915-9727
Mailing Address - Fax:
Practice Address - Street 1:5713 N PERSHING AVE STE A3
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4910
Practice Address - Country:US
Practice Address - Phone:209-488-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist