1043633761 NPI number — LODI MEMORIAL HOSPTIAL PHARMACY WEST

Table of content: (NPI 1043633761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043633761 NPI number — LODI MEMORIAL HOSPTIAL PHARMACY WEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LODI MEMORIAL HOSPTIAL PHARMACY WEST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043633761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2415 W VILNE #104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LODI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95240-5118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-334-3411
Provider Business Mailing Address Fax Number:
209-333-3110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975 S FAIRMONT AVE
Provider Second Line Business Practice Location Address:
2415 W VINE #104
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95240-5118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-334-3411
Provider Business Practice Location Address Fax Number:
209-333-3110
Provider Enumeration Date:
01/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SEY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ADMISTRATIVE OFFICER
Authorized Official Telephone Number:
209-339-7439

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  HSP37642 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com