Provider Demographics
NPI:1336869593
Name:TAN, RAYMOND (PHARMACIST)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10990 SAN DIEGO MISSION RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2417
Practice Address - Country:US
Practice Address - Phone:707-297-2988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist