Provider Demographics
NPI:1063825271
Name:WONG, WAI TAI (RPH, APH)
Entity Type:Individual
Prefix:
First Name:WAI TAI
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:RPH, APH
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH, APH
Mailing Address - Street 1:8237 ROCHESTER AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0717
Mailing Address - Country:US
Mailing Address - Phone:909-980-0999
Mailing Address - Fax:909-980-1099
Practice Address - Street 1:8237 ROCHESTER AVE STE 120
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0717
Practice Address - Country:US
Practice Address - Phone:909-980-0999
Practice Address - Fax:909-980-1099
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist