Healthcare Provider Details

I. General information

NPI: 1699683292
Provider Name (Legal Business Name): MICHAEL FAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 ROBIN RD
SAN MARINO CA
91108-2831
US

IV. Provider business mailing address

2065 ROBIN RD
SAN MARINO CA
91108-2831
US

V. Phone/Fax

Practice location:
  • Phone: 626-617-8791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number92798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: