Healthcare Provider Details

I. General information

NPI: 1417569567
Provider Name (Legal Business Name): JIAQI WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1985 ZONAL AVE
LOS ANGELES CA
90089-5305
US

IV. Provider business mailing address

602, UNITE 2, BUILDING 17, TAIPINGJIAO SIX RD.
QINGDAO SHANDONG
266071
CA

V. Phone/Fax

Practice location:
  • Phone: 323-442-1369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number89755
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: