Provider Demographics
NPI:1972030690
Name:ICHWAN, AYE WIN TIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:AYE
Middle Name:WIN TIN
Last Name:ICHWAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12051 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-3084
Mailing Address - Country:US
Mailing Address - Phone:562-484-9849
Mailing Address - Fax:
Practice Address - Street 1:2701 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-2518
Practice Address - Country:US
Practice Address - Phone:650-330-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist