Provider Demographics
NPI:1083251854
Name:WONG, EVAN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8267 246TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3983 LACONIA AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4916
Practice Address - Country:US
Practice Address - Phone:929-368-3873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066369-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist