MEDICARE: YINGJIE TAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS62119	FL

General Provider Information

NPI Number	:	1104497676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YINGJIE TAN

Provider Business Mailing Address
First Line	:	282 ERIN LN
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-5633
Country	:	US
Telephone Number	:	321-266-0239
Fax Number	:

Provider Business Practice Location Address
First Line	:	6257 N US HIGHWAY 1
Second Line	:
City	:	PORT ST JOHN
State	:	FL
Zip	:	32927-4925
Country	:	US
Telephone Number	:	321-633-8150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2021
Last Update Date	:	07/07/2021

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Directions to “ YINGJIE TAN ” Practice Location

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