Provider Demographics
NPI:1407038516
Name:CHAN, LISA M
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:CHAN
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 1:1720 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1208
Mailing Address - Country:US
Mailing Address - Phone:718-998-3377
Mailing Address - Fax:718-376-5686
Practice Address - Street 1:1720 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1208
Practice Address - Country:US
Practice Address - Phone:718-998-3377
Practice Address - Fax:718-376-5686
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562454Medicaid