Provider Demographics
NPI:1124046065
Name:WONG, KIM (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 E DOSORIS LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6402
Mailing Address - Country:US
Mailing Address - Phone:631-242-4312
Mailing Address - Fax:
Practice Address - Street 1:8319 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7320
Practice Address - Country:US
Practice Address - Phone:718-424-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02710149Medicaid
NY5561310001Medicare ID - Type Unspecified