Provider Demographics
NPI:1881083897
Name:CHAN, ZACHARY HO WAN (RPH)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:HO WAN
Last Name:CHAN
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 1:960 STATE ROAD 16
Mailing Address - Street 2:APARTMENT 305
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669
Mailing Address - Country:US
Mailing Address - Phone:608-772-0817
Mailing Address - Fax:
Practice Address - Street 1:1600 W WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2242
Practice Address - Country:US
Practice Address - Phone:608-269-7843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16086-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist