Provider Demographics
NPI:1164793626
Name:CHANG, KEVIN (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:CHANG
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 1:939 LAKEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:939 LAKEVILLE HWY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3329
Practice Address - Country:US
Practice Address - Phone:707-762-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-15
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist