Provider Demographics
NPI:1043527146
Name:WONG, IVAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17615 140TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-6828
Mailing Address - Country:US
Mailing Address - Phone:425-204-1585
Mailing Address - Fax:425-204-0743
Practice Address - Street 1:17615 140TH AVE SE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058
Practice Address - Country:US
Practice Address - Phone:425-204-1585
Practice Address - Fax:425-204-0743
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00063119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist