Provider Demographics
NPI:1053540062
Name:YANG, LUCKY
Entity type:Individual
Prefix:MR
First Name:LUCKY
Middle Name:
Last Name:YANG
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 1:4152 LAKELAND AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1832
Mailing Address - Country:US
Mailing Address - Phone:763-535-2459
Mailing Address - Fax:763-535-6063
Practice Address - Street 1:1933 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7131
Practice Address - Country:US
Practice Address - Phone:508-587-0235
Practice Address - Fax:508-584-0874
Is Sole Proprietor?:No
Enumeration Date:2009-07-11
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122629183500000X
MA24903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist