Provider Demographics
NPI:1841584638
Name:FANG, CARY
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:
Last Name:FANG
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 1:20700 AVALON BLVD STE 750
Mailing Address - Street 2:T-2026
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3724
Mailing Address - Country:US
Mailing Address - Phone:310-819-3012
Mailing Address - Fax:310-819-3012
Practice Address - Street 1:20700 AVALON BLVD STE 750
Practice Address - Street 2:T-2026
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3724
Practice Address - Country:US
Practice Address - Phone:310-819-3012
Practice Address - Fax:310-819-3012
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist