Provider Demographics
NPI:1053915264
Name:CHAN, CYNTHIA (RPH)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-8517
Mailing Address - Country:US
Mailing Address - Phone:781-642-7416
Mailing Address - Fax:
Practice Address - Street 1:55 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-8517
Practice Address - Country:US
Practice Address - Phone:781-642-7416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist