1083759625 NPI number — MOTHER LODE DRUG COMPANY

Table of content: (NPI 1083759625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083759625 NPI number — MOTHER LODE DRUG COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOTHER LODE DRUG COMPANY
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:
1083759625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2099
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIPOSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95338-2099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-742-7600
Provider Business Mailing Address Fax Number:
209-742-7500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5034 COAKLEY CIRCLE DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIPOSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95338-2099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-742-7600
Provider Business Practice Location Address Fax Number:
209-742-7500
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RADANOVICH
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
209-742-7600

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY31052 , 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)

  • Identifier: PHA310520 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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