Provider Demographics
NPI:1912315193
Name:CHAN, MONICIA
Entity Type:Individual
Prefix:
First Name:MONICIA
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 1:755 RIVERPOINT CT
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-1654
Mailing Address - Country:US
Mailing Address - Phone:916-373-2213
Mailing Address - Fax:916-373-2213
Practice Address - Street 1:755 RIVERPOINT CT
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-1654
Practice Address - Country:US
Practice Address - Phone:916-373-2213
Practice Address - Fax:916-373-2213
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist