Provider Demographics
NPI:1396358065
Name:PAN, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-1406
Mailing Address - Country:US
Mailing Address - Phone:217-732-1825
Mailing Address - Fax:217-732-7796
Practice Address - Street 1:603 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1406
Practice Address - Country:US
Practice Address - Phone:217-732-1825
Practice Address - Fax:217-732-7796
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018006777183500000X
IL051301818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist