Provider Demographics
NPI:1497355408
Name:WONG, TERI
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W PIONEER BLVD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-8864
Mailing Address - Country:US
Mailing Address - Phone:702-346-0408
Mailing Address - Fax:702-346-0916
Practice Address - Street 1:1120 W PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-8864
Practice Address - Country:US
Practice Address - Phone:702-346-0408
Practice Address - Fax:702-346-0916
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV18958183500000X
UT7945846-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist