Provider Demographics
NPI:1265279723
Name:WONG, ALICE BROOKE (PHARMD)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:BROOKE
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 1:5043 PRIVET AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-1031
Mailing Address - Country:US
Mailing Address - Phone:626-274-6197
Mailing Address - Fax:
Practice Address - Street 1:801 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-2807
Practice Address - Country:US
Practice Address - Phone:432-337-6637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX734941835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty