Provider Demographics
NPI:1093168221
Name:WONG, SIDFUN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SIDFUN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SUMMER VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-5636
Mailing Address - Country:US
Mailing Address - Phone:843-813-2303
Mailing Address - Fax:
Practice Address - Street 1:101 LOCUST ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1503
Practice Address - Country:US
Practice Address - Phone:864-439-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist