Provider Demographics
NPI:1013594753
Name:CHAN, DAVID CHUNG MAN (PHARMD, PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHUNG MAN
Last Name:CHAN
Suffix:
Gender:M
Credentials:PHARMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2006
Mailing Address - Country:US
Mailing Address - Phone:603-252-5807
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-996-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3553183500000X
IL051299074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist