Provider Demographics
NPI:1558540203
Name:WONG, JACK C (BSC)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:C
Last Name:WONG
Suffix:
Gender:M
Credentials:BSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PEREGRINE WAY
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-8784
Mailing Address - Country:US
Mailing Address - Phone:585-872-4805
Mailing Address - Fax:585-271-0172
Practice Address - Street 1:626 PARK AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-2943
Practice Address - Country:US
Practice Address - Phone:585-271-6736
Practice Address - Fax:585-271-0172
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033884-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist