Healthcare Provider Details

I. General information

NPI: 1093327694
Provider Name (Legal Business Name): SITHICHOK CHANG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

IV. Provider business mailing address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

V. Phone/Fax

Practice location:
  • Phone: 920-364-3600
  • Fax: 920-364-3900
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19936
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: