Provider Demographics
NPI:1821239054
Name:WONG, MARISELA (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:MARISELA
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:1510 N. SANTA FE AVENUE
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083
Mailing Address - Country:US
Mailing Address - Phone:760-724-3763
Mailing Address - Fax:760-724-3792
Practice Address - Street 1:1510 N. SANTA FE AVENUE
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083
Practice Address - Country:US
Practice Address - Phone:760-724-3763
Practice Address - Fax:760-724-3792
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist