Provider Demographics
NPI:1649718792
Name:CHAN, CHERYL
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20236 E WALNUT CANYON RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4412
Mailing Address - Country:US
Mailing Address - Phone:626-475-3313
Mailing Address - Fax:
Practice Address - Street 1:1255 W ARROW HWY
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2340
Practice Address - Country:US
Practice Address - Phone:909-394-2522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist