MEDICARE: MICKEY K WONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS0022308	FL

General Provider Information

NPI Number	:	1487939427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICKEY K WONG

Provider Business Mailing Address
First Line	:	9706 CYPRESS BROOK RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-1805
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9706 CYPRESS BROOK RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-1805
Country	:	US
Telephone Number	:	813-294-1199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2011
Last Update Date	:	10/20/2011

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Directions to “ MICKEY K WONG ” Practice Location

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