MEDICARE: MISS PO T WONG PHARM D

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	54366	CA

General Provider Information

NPI Number	:	1912288853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS PO T WONG PHARM D

Provider Business Mailing Address
First Line	:	16145 SIERRA LAKES PKWY
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-1243
Country	:	US
Telephone Number	:	909-356-9167
Fax Number	:	909-356-9172

Provider Business Practice Location Address
First Line	:	16145 SIERRA LAKES PKWY
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-1243
Country	:	US
Telephone Number	:	909-356-9167
Fax Number	:	909-356-9172

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

Provider Enumeration Date	:	09/06/2011
Last Update Date	:	09/06/2011

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