Provider Demographics
NPI:1285261420
Name:WANG, MAEGAN
Entity type:Individual
Prefix:
First Name:MAEGAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16350 VENTURA BLVD STE D194
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-5300
Mailing Address - Country:US
Mailing Address - Phone:323-823-1506
Mailing Address - Fax:
Practice Address - Street 1:17071 VENTURA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4117
Practice Address - Country:US
Practice Address - Phone:818-788-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist