Healthcare Provider Details

I. General information

NPI: 1114834850
Provider Name (Legal Business Name): KAITLIN CHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 E LA PALMA AVE STE 240
ANAHEIM CA
92807-1842
US

IV. Provider business mailing address

2071 PUEBLO
TUSTIN CA
92782-8323
US

V. Phone/Fax

Practice location:
  • Phone: 714-279-6208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number92777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: