Provider Demographics
NPI:1942211693
Name:CHAN, WILLIE (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:CHAN
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 1:261 S MOSS HILL DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1361
Mailing Address - Country:US
Mailing Address - Phone:801-840-4355
Mailing Address - Fax:801-840-4357
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-3454
Practice Address - Country:US
Practice Address - Phone:801-840-4355
Practice Address - Fax:801-840-4357
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145564-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist