Basic Information
| Provider Information | |||||||||
| NPI: | 1538887286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | YANG | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10658 FAIRHALL ST APT 6 | ||||||||
| Address2: | |||||||||
| City: | TEMPLE CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917804147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262333166 | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088855000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2022 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 85251 | CA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 85251 | 01 | CA | REGISTERED PHARMACIST LICENSE | OTHER |