Provider Demographics
NPI:1609465467
Name:WAN, PHILLIP (RPH)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WAN
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 1:1205 HANCOCK ST APT 611
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4355
Mailing Address - Country:US
Mailing Address - Phone:617-650-5578
Mailing Address - Fax:
Practice Address - Street 1:10 BASSETT ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5507
Practice Address - Country:US
Practice Address - Phone:617-698-2805
Practice Address - Fax:617-696-7275
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist