Provider Demographics
NPI:1093080947
Name:BONG, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:BONG
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 1:3768 ROCKY CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:DEPOE BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97341-9781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 NE 20TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-1851
Practice Address - Country:US
Practice Address - Phone:541-574-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-11
Last Update Date:2012-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011624183500000X
IL286836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist