Provider Demographics
NPI:1083174437
Name:WONG, WHITNEY
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:LA
Mailing Address - Zip Code:70669-6619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 NELSON RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4118
Practice Address - Country:US
Practice Address - Phone:337-475-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66140183500000X
LAPST.022874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist