Provider Demographics
NPI:1194406157
Name:CHAN, DIANA (PHARMD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 JAMES RD
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8648
Mailing Address - Country:US
Mailing Address - Phone:503-970-4144
Mailing Address - Fax:
Practice Address - Street 1:221 MAIN ST
Practice Address - Street 2:
Practice Address - City:ENOSBURG FALLS
Practice Address - State:VT
Practice Address - Zip Code:05450-6109
Practice Address - Country:US
Practice Address - Phone:802-933-7756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0330134180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist