Provider Demographics
NPI:1467058354
Name:TAN, KAROL
Entity Type:Individual
Prefix:
First Name:KAROL
Middle Name:
Last Name:TAN
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 1:282 FAYETTE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-1646
Mailing Address - Country:US
Mailing Address - Phone:815-575-5790
Mailing Address - Fax:
Practice Address - Street 1:189 SUMMER ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-1247
Practice Address - Country:US
Practice Address - Phone:781-585-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH237065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist