Provider Demographics
NPI:1649996752
Name:CHEN, SIMON (RPH)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:CHEN
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 1:210 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1411
Mailing Address - Country:US
Mailing Address - Phone:574-259-1130
Mailing Address - Fax:574-257-7920
Practice Address - Street 1:210 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1411
Practice Address - Country:US
Practice Address - Phone:574-259-1130
Practice Address - Fax:574-257-7920
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029183A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist