Healthcare Provider Details

I. General information

NPI: 1396055075
Provider Name (Legal Business Name): INDRIANI WANG PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 EMBARCADERO SUITE 400
OAKLAND CA
94606-5334
US

IV. Provider business mailing address

112 CROSBY CT #4
WALNUT CREEK CA
94598-1829
US

V. Phone/Fax

Practice location:
  • Phone: 510-567-8101
  • Fax: 510-567-6850
Mailing address:
  • Phone: 510-567-8101
  • Fax: 510-567-6850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number61256
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: