Provider Demographics
NPI:1972167047
Name:CHANG, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4785 GRANITE DR
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2853
Practice Address - Country:US
Practice Address - Phone:916-624-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty