Provider Demographics
NPI:1497293690
Name:CHAN, EDWIN C (BPHARM, MBA)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:C
Last Name:CHAN
Suffix:
Gender:M
Credentials:BPHARM, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1537
Mailing Address - Country:US
Mailing Address - Phone:909-908-4426
Mailing Address - Fax:
Practice Address - Street 1:1235 W 18TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1537
Practice Address - Country:US
Practice Address - Phone:909-908-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist