Provider Demographics
NPI:1720260771
Name:CHAN, HEATHER W (BA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:W
Last Name:CHAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:408 GRAND ST
Mailing Address - Street 2:C/O RITE AID
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4702
Mailing Address - Country:US
Mailing Address - Phone:917-676-6100
Mailing Address - Fax:212-598-5961
Practice Address - Street 1:408 GRAND ST
Practice Address - Street 2:C/O RITE AID
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4702
Practice Address - Country:US
Practice Address - Phone:917-676-6100
Practice Address - Fax:212-598-5961
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-01
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY048053-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist