Provider Demographics
NPI:1992115877
Name:WANG, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
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 1:5325 VIA PISA
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-7007
Mailing Address - Country:US
Mailing Address - Phone:805-498-2793
Mailing Address - Fax:
Practice Address - Street 1:2241 MICHAEL DR
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-3340
Practice Address - Country:US
Practice Address - Phone:805-375-6650
Practice Address - Fax:805-375-6654
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH46043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist