Provider Demographics
NPI:1316402126
Name:CHANG, TIFFANY SAN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SAN
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23958 HESPERIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-7241
Mailing Address - Country:US
Mailing Address - Phone:510-786-9174
Mailing Address - Fax:
Practice Address - Street 1:23958 HESPERIAN BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-7241
Practice Address - Country:US
Practice Address - Phone:510-786-9174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA81568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program