Provider Demographics
NPI:1194007633
Name:CHAN, ANTHONY (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W 36TH ST
Mailing Address - Street 2:UNIT 5
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1591
Mailing Address - Country:US
Mailing Address - Phone:312-523-3892
Mailing Address - Fax:312-226-7926
Practice Address - Street 1:2340 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2228
Practice Address - Country:US
Practice Address - Phone:312-226-7913
Practice Address - Fax:312-226-7926
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-11
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist