Provider Demographics
NPI:1629350897
Name:AN, DANIEL QUOC
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:QUOC
Last Name:AN
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 1:290 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904
Mailing Address - Country:US
Mailing Address - Phone:781-581-9400
Mailing Address - Fax:781-581-3791
Practice Address - Street 1:290 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-1806
Practice Address - Country:US
Practice Address - Phone:781-581-9400
Practice Address - Fax:781-581-3791
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist