Provider Demographics
NPI:1558542878
Name:WONG, LISA (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1811
Mailing Address - Country:US
Mailing Address - Phone:718-446-0300
Mailing Address - Fax:
Practice Address - Street 1:7575 31ST AVE
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1811
Practice Address - Country:US
Practice Address - Phone:718-446-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2023-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042702Medicaid
NYI042702Medicaid