Basic Information
| Provider Information | |||||||||
| NPI: | 1043633761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LODI MEMORIAL HOSPTIAL PHARMACY WEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 W VILNE #104 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093333110 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 S FAIRMONT AVE | ||||||||
| Address2: | 2415 W VINE #104 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093333110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2014 | ||||||||
| LastUpdateDate: | 01/31/2014 | ||||||||
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| AuthorizedOfficialLastName: | SEY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093397439 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LODI MEMORIAL HOSPTIAL ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | REGISTERED PHAMRACIS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | HSP37642 | CA | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.