Healthcare Provider Details

I. General information

NPI: 1942516075
Provider Name (Legal Business Name): SU-CHING FANN R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W G ST
ONTARIO CA
91762-3228
US

IV. Provider business mailing address

21484 COLD SPRING LN
DIAMOND BAR CA
91765-3813
US

V. Phone/Fax

Practice location:
  • Phone: 909-984-3913
  • Fax:
Mailing address:
  • Phone: 909-918-7268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH 42473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: