Provider Demographics
NPI:1093080822
Name:WONG, MARILYN (BS)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3515
Mailing Address - Country:US
Mailing Address - Phone:541-296-1748
Mailing Address - Fax:541-296-1756
Practice Address - Street 1:1215 W 6TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3515
Practice Address - Country:US
Practice Address - Phone:541-296-1748
Practice Address - Fax:541-296-1756
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6426183500000X
ORRPH00064261835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist