Provider Demographics
NPI:1790060374
Name:WONG, KIMBERLEE ANN (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEE
Middle Name:ANN
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 1:280 SPRECKELS AVE
Mailing Address - Street 2:T-1526
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-6005
Mailing Address - Country:US
Mailing Address - Phone:209-823-9982
Mailing Address - Fax:
Practice Address - Street 1:280 SPRECKELS AVE
Practice Address - Street 2:T-1526
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-6005
Practice Address - Country:US
Practice Address - Phone:209-823-9982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 66076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist