Provider Demographics
NPI:1750676052
Name:WONG, CONNIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WONG
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 1:1297 S MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-3655
Mailing Address - Country:US
Mailing Address - Phone:415-793-5570
Mailing Address - Fax:
Practice Address - Street 1:1297 S MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-3655
Practice Address - Country:US
Practice Address - Phone:415-793-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64150183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist