Provider Demographics
NPI:1306909064
Name:WONG, MAE LYNE (RPH)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:LYNE
Last Name:WONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:MAE
Other - Middle Name:WOO
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:601 AUMOND RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3307
Mailing Address - Country:US
Mailing Address - Phone:706-738-1031
Mailing Address - Fax:706-733-7746
Practice Address - Street 1:3547 WALTON WAY EXT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1821
Practice Address - Country:US
Practice Address - Phone:706-733-7701
Practice Address - Fax:706-733-7746
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4032720001Medicare ID - Type Unspecified