Provider Demographics
NPI:1770001299
Name:WANG, YIZI
Entity Type:Individual
Prefix:
First Name:YIZI
Middle Name:
Last Name:WANG
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 1:14475 MELBOURNE AVE APT 6B
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1320
Mailing Address - Country:US
Mailing Address - Phone:646-239-5220
Mailing Address - Fax:
Practice Address - Street 1:4220 BOWNE ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2651
Practice Address - Country:US
Practice Address - Phone:929-329-0011
Practice Address - Fax:929-329-0011
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist