Provider Demographics
NPI:1487921334
Name:CHENG, IVY YA WEN (PHARMD)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:YA WEN
Last Name:CHENG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 CARNELIAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4556
Mailing Address - Country:US
Mailing Address - Phone:909-581-1157
Mailing Address - Fax:
Practice Address - Street 1:6701 CARNELIAN ST
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-4556
Practice Address - Country:US
Practice Address - Phone:909-581-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA52885OtherPHARMACIST LICENSE NUMBER