Provider Demographics
NPI:1538676804
Name:WONG, TIMOTHY (PHARMD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2506
Mailing Address - Country:US
Mailing Address - Phone:626-305-9112
Mailing Address - Fax:
Practice Address - Street 1:165 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2506
Practice Address - Country:US
Practice Address - Phone:626-305-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA52701OtherCALIFORNIA STATE BOARD OF PHARMACY