Provider Demographics
NPI:1851876643
Name:WONG, MAGGIE C
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:C
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4156 PECK RD APT D
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-2252
Mailing Address - Country:US
Mailing Address - Phone:626-454-0972
Mailing Address - Fax:
Practice Address - Street 1:1954 DURFEE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-3711
Practice Address - Country:US
Practice Address - Phone:626-350-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist