Provider Demographics
NPI:1003832247
Name:WOLF, PATRICIA WONG (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:WONG
Last Name:WOLF
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 100-D
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2800
Mailing Address - Country:US
Mailing Address - Phone:662-843-4214
Mailing Address - Fax:
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:SUITE 100-D
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2800
Practice Address - Country:US
Practice Address - Phone:662-843-4214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-5726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030115Medicaid
2513592OtherNABP