Provider Demographics
NPI:1407376023
Name:CHANG, CHANGPO
Entity Type:Individual
Prefix:
First Name:CHANGPO
Middle Name:
Last Name:CHANG
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 1:308 E COSTERA CT
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-4152
Mailing Address - Country:US
Mailing Address - Phone:909-319-2750
Mailing Address - Fax:
Practice Address - Street 1:16455 MAIN ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3554
Practice Address - Country:US
Practice Address - Phone:760-998-2991
Practice Address - Fax:310-214-8282
Is Sole Proprietor?:No
Enumeration Date:2017-06-24
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist