Provider Demographics
NPI:1477677987
Name:WONG, PETER J (RPH)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:J
Last Name:WONG
Suffix:
Gender:M
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:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:BANKS
Mailing Address - State:OR
Mailing Address - Zip Code:97106-0667
Mailing Address - Country:US
Mailing Address - Phone:503-621-3604
Mailing Address - Fax:
Practice Address - Street 1:14625 SW ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-3600
Practice Address - Country:US
Practice Address - Phone:503-643-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist