Provider Demographics
NPI:1679895254
Name:CHAN, MICHAEL VINCENT (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:CHAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931D CONKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2429
Mailing Address - Country:US
Mailing Address - Phone:800-346-6348
Mailing Address - Fax:866-689-3569
Practice Address - Street 1:931D CONKLIN STREET
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2429
Practice Address - Country:US
Practice Address - Phone:800-346-6348
Practice Address - Fax:866-689-3569
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist