Provider Demographics
NPI:1902046535
Name:WONG, LISA DENTON (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DENTON
Last Name:WONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 W COSTCO DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2864
Mailing Address - Country:US
Mailing Address - Phone:520-797-8190
Mailing Address - Fax:520-797-4637
Practice Address - Street 1:3901 W COSTCO DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2864
Practice Address - Country:US
Practice Address - Phone:520-797-8190
Practice Address - Fax:520-797-4637
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS007051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist