Provider Demographics
NPI:1427314806
Name:WONG, SUSAN L
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:WONG
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 1:3300 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-5400
Mailing Address - Country:US
Mailing Address - Phone:503-537-1383
Mailing Address - Fax:
Practice Address - Street 1:3300 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-5400
Practice Address - Country:US
Practice Address - Phone:503-537-1383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0008033183500000X
CARPH 44277183500000X, 1835P0018X
ORRPH-00080331835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist