Provider Demographics
NPI:1821343930
Name:WONG, PHILLIP (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-3126
Mailing Address - Country:US
Mailing Address - Phone:315-255-1761
Mailing Address - Fax:315-255-2152
Practice Address - Street 1:352 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3126
Practice Address - Country:US
Practice Address - Phone:315-255-1761
Practice Address - Fax:315-255-2152
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist