Provider Demographics
NPI:1639543648
Name:FANG, DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FANG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W 25TH PL APT F
Mailing Address - Street 2:APT F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4546
Mailing Address - Country:US
Mailing Address - Phone:312-622-6043
Mailing Address - Fax:
Practice Address - Street 1:333 W 25TH PL APT F
Practice Address - Street 2:APT F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4546
Practice Address - Country:US
Practice Address - Phone:312-622-6043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP450096183500000X
PARPI010125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist