Provider Demographics
NPI:1770651028
Name:WO, KEVIN (RPH)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 DEEPDALE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1831
Mailing Address - Country:US
Mailing Address - Phone:718-915-3697
Mailing Address - Fax:
Practice Address - Street 1:28 BOWERY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5100
Practice Address - Country:US
Practice Address - Phone:212-240-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist