Provider Demographics
NPI:1891017414
Name:WAN, ANTHEA (PHARM D)
Entity Type:Individual
Prefix:
First Name:ANTHEA
Middle Name:
Last Name:WAN
Suffix:
Gender:F
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 1:10962 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1753
Mailing Address - Country:US
Mailing Address - Phone:718-740-4612
Mailing Address - Fax:
Practice Address - Street 1:10962 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1753
Practice Address - Country:US
Practice Address - Phone:718-740-4612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist