Provider Demographics
NPI:1194907220
Name:WANG, SHAN
Entity type:Individual
Prefix:
First Name:SHAN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8808 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4437
Mailing Address - Country:US
Mailing Address - Phone:718-803-3005
Mailing Address - Fax:718-803-3346
Practice Address - Street 1:8808 55TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4437
Practice Address - Country:US
Practice Address - Phone:718-803-3005
Practice Address - Fax:718-803-3346
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY048389OtherBOARD OF PHARMACY