Provider Demographics
NPI:1992129761
Name:WONG, KATHLEEN (PHARMD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 TENNESSEE ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-3421
Mailing Address - Country:US
Mailing Address - Phone:800-874-5881
Mailing Address - Fax:
Practice Address - Street 1:1400 TENNESSEE ST UNIT 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-3421
Practice Address - Country:US
Practice Address - Phone:800-874-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68812183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist