Provider Demographics
NPI:1275123846
Name:WU, KWANTA NATHALANG (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KWANTA
Middle Name:NATHALANG
Last Name:WU
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 1:13021 FOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4744
Mailing Address - Country:US
Mailing Address - Phone:574-323-7802
Mailing Address - Fax:
Practice Address - Street 1:1654 E MARKET ST # 06467
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-2339
Practice Address - Country:US
Practice Address - Phone:574-773-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292180183500000X
MI5302047304183500000X
IN26022731A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist