Provider Demographics
NPI:1104860618
Name:CHAN, G (PHARMD)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 W BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-1818
Mailing Address - Country:US
Mailing Address - Phone:805-481-8640
Mailing Address - Fax:805-481-0106
Practice Address - Street 1:1570 W BRANCH ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1818
Practice Address - Country:US
Practice Address - Phone:805-481-8640
Practice Address - Fax:805-481-0106
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist