Provider Demographics
NPI:1093319717
Name:WONG, AMANDA (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1138
Mailing Address - Country:US
Mailing Address - Phone:617-740-0611
Mailing Address - Fax:
Practice Address - Street 1:451 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1138
Practice Address - Country:US
Practice Address - Phone:617-740-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH238953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist