Provider Demographics
NPI:1912180373
Name:WONG, JUAN S
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:S
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:S
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS IN PHARMACY
Mailing Address - Street 1:453 62ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-4507
Mailing Address - Country:US
Mailing Address - Phone:718-249-7032
Mailing Address - Fax:718-499-3547
Practice Address - Street 1:462 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4004
Practice Address - Country:US
Practice Address - Phone:718-499-7500
Practice Address - Fax:718-499-3547
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039207183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00895538Medicaid