Provider Demographics
NPI:1194964189
Name:WAN, INNESS MAN-WING (RPH)
Entity type:Individual
Prefix:
First Name:INNESS
Middle Name:MAN-WING
Last Name:WAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N LONE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1725
Mailing Address - Country:US
Mailing Address - Phone:909-962-5516
Mailing Address - Fax:909-962-5513
Practice Address - Street 1:520 N LONE HILL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1725
Practice Address - Country:US
Practice Address - Phone:909-962-5516
Practice Address - Fax:909-962-5513
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist