Provider Demographics
NPI:1114682739
Name:TAN, ALEXIS VIANCA TAN (RPH)
Entity Type:Individual
Prefix:
First Name:ALEXIS VIANCA
Middle Name:TAN
Last Name:TAN
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 1:2530 GLENDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-3220
Mailing Address - Country:US
Mailing Address - Phone:323-666-1285
Mailing Address - Fax:
Practice Address - Street 1:2530 GLENDALE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-3220
Practice Address - Country:US
Practice Address - Phone:323-666-1285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist