Provider Demographics
NPI:1346658986
Name:WONG, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5531
Mailing Address - Country:US
Mailing Address - Phone:714-491-1778
Mailing Address - Fax:
Practice Address - Street 1:440 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5531
Practice Address - Country:US
Practice Address - Phone:714-491-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist