MEDICARE: PROVISION PHARMACY, INC.

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1417811647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVISION PHARMACY, INC.

Provider Business Mailing Address
First Line	:	4428 GLACIER AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3304
Country	:	US
Telephone Number	:	808-854-8999
Fax Number	:

Provider Business Practice Location Address
First Line	:	4428 GLACIER AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3304
Country	:	US
Telephone Number	:	808-854-8999
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. ALAN CHAN
Credential	:	PHARM.D
Telephone Number	:	808-854-8999

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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