Provider Demographics
NPI:1619245297
Name:MA, WELLA JUN (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:WELLA
Middle Name:JUN
Last Name:MA
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 1:3944 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5422
Mailing Address - Country:US
Mailing Address - Phone:909-364-0725
Mailing Address - Fax:
Practice Address - Street 1:3944 GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5422
Practice Address - Country:US
Practice Address - Phone:909-364-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist