Provider Demographics
NPI:1386130334
Name:WONG, JON JAMES (RPH)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:JAMES
Last Name:WONG
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 1:123 NE 172ND AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6465
Mailing Address - Country:US
Mailing Address - Phone:971-225-0183
Mailing Address - Fax:
Practice Address - Street 1:123 NE 172ND AVE APT 217
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6465
Practice Address - Country:US
Practice Address - Phone:971-225-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00046153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist