Provider Demographics
NPI:1255757688
Name:WONG, LILY
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:WONG
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 1:3455 KEARNY VILLA RD APT 413
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1984
Mailing Address - Country:US
Mailing Address - Phone:415-203-5834
Mailing Address - Fax:
Practice Address - Street 1:3455 KEARNY VILLA RD
Practice Address - Street 2:APT 413
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1971
Practice Address - Country:US
Practice Address - Phone:415-203-5834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist