Provider Demographics
NPI:1710583182
Name:FU, WANTI
Entity Type:Individual
Prefix:
First Name:WANTI
Middle Name:
Last Name:FU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10666 E NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-4835
Mailing Address - Country:US
Mailing Address - Phone:214-349-2530
Mailing Address - Fax:
Practice Address - Street 1:10666 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-4835
Practice Address - Country:US
Practice Address - Phone:214-349-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty