MEDICARE: KEITH RICHARD WONG PHARMD

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	46369	TX

General Provider Information

NPI Number	:	1598083388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH RICHARD WONG PHARMD

Provider Business Mailing Address
First Line	:	4955 HIGHWAY 6 N
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-2718
Country	:	US
Telephone Number	:	281-463-9148
Fax Number	:	281-463-9165

Provider Business Practice Location Address
First Line	:	4955 HIGHWAY 6 N
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-2718
Country	:	US
Telephone Number	:	281-463-9148
Fax Number	:	281-463-9165

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

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	05/04/2010

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