Provider Demographics
NPI:1407110638
Name:CHAN, TAKKEUNG KENNETH (RPH)
Entity Type:Individual
Prefix:MR
First Name:TAKKEUNG
Middle Name:KENNETH
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 1:1400 PARKMOOR #120A
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3797
Mailing Address - Country:US
Mailing Address - Phone:408-793-2759
Mailing Address - Fax:
Practice Address - Street 1:1400 PARKMOOR AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3797
Practice Address - Country:US
Practice Address - Phone:408-793-2759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43610OtherPHARMCIST LICENSE NUMBER