=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649684820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. CRYSTAL CHAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2014
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5880 STOCKTON BLVD STE C
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95824-3055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-706-0278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4831 D ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-320-3927
-----------------------------------------------------
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 | 69370
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------