Provider Demographics
NPI:1760084891
Name:FAN, ALEX (PHARM D)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:FAN
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 1:200 N HILLS ST APT 12D
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-2232
Mailing Address - Country:US
Mailing Address - Phone:601-447-2941
Mailing Address - Fax:
Practice Address - Street 1:3310 MS-39
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:601-286-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-16629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist