Provider Demographics
NPI:1477896637
Name:FAN, SHUTIENG (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHUTIENG
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7001 S LA CIENEGA BLVD APT 213
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-2055
Mailing Address - Country:US
Mailing Address - Phone:909-837-5761
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program