Provider Demographics
NPI:1083947246
Name:WONG, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
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 1:1377 NE STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2159
Mailing Address - Country:US
Mailing Address - Phone:541-672-1509
Mailing Address - Fax:541-677-7231
Practice Address - Street 1:1377 NE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2159
Practice Address - Country:US
Practice Address - Phone:541-672-1509
Practice Address - Fax:541-677-7231
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist