MEDICARE: MICHAEL WAN PHARMD

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	74190	CA
2	183500000X	Pharmacist	PHA.0021036	CO

General Provider Information

NPI Number	:	1134580061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WAN PHARMD

Provider Business Mailing Address
First Line	:	2456 S GROVE AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-6224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2456 S GROVE AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-6224
Country	:	US
Telephone Number	:	909-947-9390
Fax Number	:

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

Provider Enumeration Date	:	03/20/2016
Last Update Date	:	03/20/2016

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