Healthcare Provider Details

I. General information

NPI: 1043527146
Provider Name (Legal Business Name): IVAN WONG PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17615 140TH AVE SE
RENTON WA
98058
US

IV. Provider business mailing address

17615 140TH AVE SE
RENTON WA
98058-6828
US

V. Phone/Fax

Practice location:
  • Phone: 425-204-1585
  • Fax: 425-204-0743
Mailing address:
  • Phone: 425-204-1585
  • Fax: 425-204-0743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00063119
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: