Provider Demographics
NPI:1194130062
Name:WONG, DOUGLAS
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WONG
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 1:700 E KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-5612
Mailing Address - Country:US
Mailing Address - Phone:215-628-0867
Mailing Address - Fax:845-483-1649
Practice Address - Street 1:700 E KENNEDY RD
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-5612
Practice Address - Country:US
Practice Address - Phone:215-628-0867
Practice Address - Fax:845-483-1649
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30301183500000X
PARP043566R183500000X
MAPH18267183500000X
NV06823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist