Provider Demographics
NPI:1023391109
Name:WONG, TINA (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19726 CRYSTAL RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3857
Mailing Address - Country:US
Mailing Address - Phone:818-832-8541
Mailing Address - Fax:
Practice Address - Street 1:13231 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2025
Practice Address - Country:US
Practice Address - Phone:818-623-9358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist