Provider Demographics
NPI:1750932687
Name:WONG, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
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 1:3266 47TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1731
Mailing Address - Country:US
Mailing Address - Phone:646-340-6843
Mailing Address - Fax:
Practice Address - Street 1:7815 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1221
Practice Address - Country:US
Practice Address - Phone:718-429-2042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist