Provider Demographics
NPI:1912288853
Name:WONG, PO T (PHARM D)
Entity type:Individual
Prefix:MISS
First Name:PO
Middle Name:T
Last Name:WONG
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16145 SIERRA LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1243
Mailing Address - Country:US
Mailing Address - Phone:909-356-9167
Mailing Address - Fax:909-356-9172
Practice Address - Street 1:16145 SIERRA LAKES PKWY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1243
Practice Address - Country:US
Practice Address - Phone:909-356-9167
Practice Address - Fax:909-356-9172
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist