Provider Demographics
NPI:1902437684
Name:YANG, PHENG M (RPH)
Entity Type:Individual
Prefix:
First Name:PHENG
Middle Name:M
Last Name:YANG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37050 S GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2700
Mailing Address - Country:US
Mailing Address - Phone:586-463-3110
Mailing Address - Fax:586-463-0483
Practice Address - Street 1:37050 S GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-2700
Practice Address - Country:US
Practice Address - Phone:586-463-3110
Practice Address - Fax:586-463-0483
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist