Healthcare Provider Details

I. General information

NPI: 1013594753
Provider Name (Legal Business Name): DAVID CHUNG MAN CHAN PHARMD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 03/27/2021
Certification Date: 03/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

3215 CENTRAL AVE
WILMETTE IL
60091-2006
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-4541
  • Fax:
Mailing address:
  • Phone: 603-252-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3553
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051299074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: