Provider Demographics
NPI:1790979771
Name:WONG, JOHN WS (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WS
Last Name:WONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:747 INDIAN BOUNDARY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1518
Mailing Address - Country:US
Mailing Address - Phone:219-926-8723
Mailing Address - Fax:219-983-1930
Practice Address - Street 1:747 INDIAN BOUNDARY RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-1518
Practice Address - Country:US
Practice Address - Phone:219-926-8723
Practice Address - Fax:219-983-1930
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015813183500000X
HIPH-2130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist