Provider Demographics
NPI:1689974107
Name:CHANG, MARK NICHOLAS (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NICHOLAS
Last Name:CHANG
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 EL CAMINO AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4602
Mailing Address - Country:US
Mailing Address - Phone:415-722-2052
Mailing Address - Fax:
Practice Address - Street 1:2214 EL CAMINO AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-4602
Practice Address - Country:US
Practice Address - Phone:415-722-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist