Provider Demographics
NPI:1215459573
Name:CHANG, MAITONG (RPH)
Entity type:Individual
Prefix:
First Name:MAITONG
Middle Name:
Last Name:CHANG
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 1:1214 175TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-8249
Mailing Address - Country:US
Mailing Address - Phone:425-599-7704
Mailing Address - Fax:
Practice Address - Street 1:3625 148TH ST SW STE B
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-5577
Practice Address - Country:US
Practice Address - Phone:425-742-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60667762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist