Provider Demographics
NPI:1821690561
Name:CHANG, GLENN MAXWELL (RPH)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MAXWELL
Last Name:CHANG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9154 WOOLLEY ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1349
Mailing Address - Country:US
Mailing Address - Phone:626-231-9203
Mailing Address - Fax:
Practice Address - Street 1:150 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3236
Practice Address - Country:US
Practice Address - Phone:626-231-9203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist