Provider Demographics
NPI:1538787262
Name:GAN, RAYMOND (RPH)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:GAN
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 1:7209 164TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4221
Mailing Address - Country:US
Mailing Address - Phone:347-264-5615
Mailing Address - Fax:
Practice Address - Street 1:598 MERRICK RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5445
Practice Address - Country:US
Practice Address - Phone:516-764-1953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist