Provider Demographics
NPI:1104497676
Name:TAN, YINGJIE
Entity type:Individual
Prefix:
First Name:YINGJIE
Middle Name:
Last Name:TAN
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 1:282 ERIN LN
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5633
Mailing Address - Country:US
Mailing Address - Phone:321-266-0239
Mailing Address - Fax:
Practice Address - Street 1:6257 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4925
Practice Address - Country:US
Practice Address - Phone:321-633-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist