Provider Demographics
NPI:1720481757
Name:WONG, WENDY (RPH)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 NE 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4505
Mailing Address - Country:US
Mailing Address - Phone:360-885-0184
Mailing Address - Fax:
Practice Address - Street 1:221 NE 104TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-4505
Practice Address - Country:US
Practice Address - Phone:360-885-0184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00019017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6021463Medicaid