1154512226 NPI number — LIMS SHASTA LAKE PHARMACY INC

Table of content: (NPI 1154512226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154512226 NPI number — LIMS SHASTA LAKE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIMS SHASTA LAKE PHARMACY INC
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:
6
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:
1154512226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4215 FRONT ST
Provider Second Line Business Mailing Address:
STE 31
Provider Business Mailing Address City Name:
SHASTA LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96019-9430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-275-2100
Provider Business Mailing Address Fax Number:
530-275-5900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4215 FRONT ST
Provider Second Line Business Practice Location Address:
STE 31
Provider Business Practice Location Address City Name:
SHASTA LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96019-9430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-275-2100
Provider Business Practice Location Address Fax Number:
530-275-5900
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LIM
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
530-941-1179

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY48558 , 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: 5627748 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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