Provider Demographics
NPI:1013297084
Name:SANGBONG, VERA BONG
Entity Type:Individual
Prefix:MRS
First Name:VERA
Middle Name:BONG
Last Name:SANGBONG
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 1:6309 HOLLAND MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAYTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20882-1235
Mailing Address - Country:US
Mailing Address - Phone:240-793-2701
Mailing Address - Fax:
Practice Address - Street 1:9807 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872
Practice Address - Country:US
Practice Address - Phone:301-391-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12373183500000X
VA0202010513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist