Provider Demographics
NPI:1942537881
Name:WANG, WAYNE
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 MELBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3138
Mailing Address - Country:US
Mailing Address - Phone:858-366-8732
Mailing Address - Fax:
Practice Address - Street 1:501 E BELT LINE RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2210
Practice Address - Country:US
Practice Address - Phone:972-291-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist