Basic Information
Provider Information | |||||||||
NPI: | 1972910743 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LODI HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2415 W VINE ST | ||||||||
Address2: |   | ||||||||
City: | LODI | ||||||||
State: | CA | ||||||||
PostalCode: | 952423731 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093333009 | ||||||||
FaxNumber: | 2093333110 | ||||||||
Practice Location | |||||||||
Address1: | 2415 W VINE ST | ||||||||
Address2: |   | ||||||||
City: | LODI | ||||||||
State: | CA | ||||||||
PostalCode: | 952423731 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093333009 | ||||||||
FaxNumber: | 2093333110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2014 | ||||||||
LastUpdateDate: | 07/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AIROLLA | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PHARMACIST IN CHARGE | ||||||||
AuthorizedOfficialTelephone: | 2093333060 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | 59860 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacy Technician |   |
No ID Information.