Provider Demographics
NPI:1992176259
Name:WONG, KELLY (PHARM D)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
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 1:10871 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737
Mailing Address - Country:US
Mailing Address - Phone:909-921-8492
Mailing Address - Fax:
Practice Address - Street 1:1120 S NT VERNON AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-783-0390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH40823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist