Provider Demographics
NPI:1730526948
Name:KONG, KAN W (RPH)
Entity type:Individual
Prefix:
First Name:KAN
Middle Name:W
Last Name:KONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 CONJURERS DR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2172
Mailing Address - Country:US
Mailing Address - Phone:804-458-1231
Mailing Address - Fax:804-458-6742
Practice Address - Street 1:2305 OAKLAWN BLVD
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-5032
Practice Address - Country:US
Practice Address - Phone:804-458-1231
Practice Address - Fax:804-458-6742
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist