Provider Demographics
NPI:1407266786
Name:WONG, KELLIANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLIANNE
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 1:1703 TERMINO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2124
Mailing Address - Country:US
Mailing Address - Phone:562-597-7733
Mailing Address - Fax:562-498-1171
Practice Address - Street 1:1703 TERMINO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2124
Practice Address - Country:US
Practice Address - Phone:562-597-7733
Practice Address - Fax:562-498-1171
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH42950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist