Provider Demographics
NPI:1609079243
Name:WONG, IVY (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 69TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2854
Mailing Address - Country:US
Mailing Address - Phone:718-335-7277
Mailing Address - Fax:
Practice Address - Street 1:3721 69TH ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2854
Practice Address - Country:US
Practice Address - Phone:718-335-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist