Provider Demographics
NPI:1396348496
Name:WONG, TAK
Entity type:Individual
Prefix:
First Name:TAK
Middle Name:
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 1:14241 KINGS CROSSING BLVD UNIT 100
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-4343
Mailing Address - Country:US
Mailing Address - Phone:240-899-5152
Mailing Address - Fax:
Practice Address - Street 1:16837 CRABBS BRANCH WAY
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20855-2215
Practice Address - Country:US
Practice Address - Phone:301-840-1777
Practice Address - Fax:844-411-6258
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist