Provider Demographics
NPI:1538717632
Name:FAN, MICHAEL (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CITYGREEN WAY APT 302
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-1481
Mailing Address - Country:US
Mailing Address - Phone:480-639-9664
Mailing Address - Fax:
Practice Address - Street 1:3605 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-3602
Practice Address - Country:US
Practice Address - Phone:423-622-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024045183500000X
TN0000043251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist