Provider Demographics
NPI:1881687846
Name:CHAN, JOHNNY PINGHON
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:PINGHON
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 1:3137 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2959
Mailing Address - Country:US
Mailing Address - Phone:650-366-3784
Mailing Address - Fax:650-366-1848
Practice Address - Street 1:3137 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-2959
Practice Address - Country:US
Practice Address - Phone:650-366-3784
Practice Address - Fax:650-366-1848
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH32261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY11062OtherPHARMACY LICENCE
CAPHA110620Medicaid
CAPHY11062OtherPHARMACY LICENCE