=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033646013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY CHAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2017
-----------------------------------------------------
Last Update Date | 05/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 393 WINDSOR HWY
-----------------------------------------------------
City | NEW WINDSOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12553-7939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-561-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 LYNN ST
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RJ07133
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | I042917
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------