Basic Information
| Provider Information | |||||||||
| NPI: | 1003846858 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LODI HEALTH PHARMACY WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2415 W VINE ST | ||||||||
| Address2: | 104B | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093333009 | ||||||||
| FaxNumber: | 2093333110 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 W VINE ST | ||||||||
| Address2: | 104B | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093333009 | ||||||||
| FaxNumber: | 2093333110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AIROLA | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PIC/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2093333009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | PHY53672 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2003584 | 01 | PK | OTHER | PHB367420 | 05 | CA | MEDICAID |