Provider Demographics
NPI:1760766935
Name:CHAN, WELTON
Entity Type:Individual
Prefix:
First Name:WELTON
Middle Name:
Last Name:CHAN
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 1:4926 LIVE OAK ST APT E
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:CA
Mailing Address - Zip Code:90201-5229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20200 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-7821
Practice Address - Country:US
Practice Address - Phone:562-274-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZI009255183500000X
CA68187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist