Basic Information
| Provider Information | |||||||||
| NPI: | 1902119456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | CHO-MAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | R. PH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 ROUTE 112 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117633655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312079234 | ||||||||
| FaxNumber: | 6312079502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 ROUTE 112 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117633655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312079234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 054702 | NY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.