Basic Information
| Provider Information | |||||||||
| NPI: | 1003154741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILTFANG | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD, MPH, BA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WONG | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHARMD/MPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1150 5TH ST | ||||||||
| Address2: | STE 140 | ||||||||
| City: | CORALVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522412932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3195946082 | ||||||||
| FaxNumber: | 3193546050 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 JAMES ST STE 10 | ||||||||
| Address2: | |||||||||
| City: | CORALVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522411895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3195946082 | ||||||||
| FaxNumber: | 3193546050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 21754 | IA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.