Provider Demographics
NPI:1538473707
Name:WONG, STACEY LAURIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LAURIN
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 1:21508 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2949
Mailing Address - Country:US
Mailing Address - Phone:718-479-2782
Mailing Address - Fax:
Practice Address - Street 1:21508 73RD AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-2949
Practice Address - Country:US
Practice Address - Phone:718-479-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist