Provider Demographics
NPI:1174110472
Name:CHONG, CHAYSEN
Entity type:Individual
Prefix:
First Name:CHAYSEN
Middle Name:
Last Name:CHONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 E SHARPSBURG AVE APT 394
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-6691
Mailing Address - Country:US
Mailing Address - Phone:808-269-9412
Mailing Address - Fax:
Practice Address - Street 1:260 W HONEYSUCKLE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9270
Practice Address - Country:US
Practice Address - Phone:208-762-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist