Provider Demographics
NPI:1366976037
Name:CHAN, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 VIA CAMPO
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-1806
Mailing Address - Country:US
Mailing Address - Phone:323-724-6340
Mailing Address - Fax:323-724-6090
Practice Address - Street 1:2525 VIA CAMPO
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-1806
Practice Address - Country:US
Practice Address - Phone:323-724-6340
Practice Address - Fax:323-724-6090
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist