Provider Demographics
NPI:1821374885
Name:WONGKAEW, NONGNUCH AE (R PH)
Entity Type:Individual
Prefix:
First Name:NONGNUCH
Middle Name:AE
Last Name:WONGKAEW
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 140TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-4719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:647 140TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-4719
Practice Address - Country:US
Practice Address - Phone:425-603-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60116807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist