Provider Demographics
NPI:1003188533
Name:WONG, WAYNE H
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:H
Last Name:WONG
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 1:5500 RED ROCK LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6512
Mailing Address - Country:US
Mailing Address - Phone:402-421-2122
Mailing Address - Fax:402-421-2153
Practice Address - Street 1:5500 RED ROCK LN
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-6512
Practice Address - Country:US
Practice Address - Phone:402-421-2122
Practice Address - Fax:402-421-2153
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist