Provider Demographics
NPI:1003000258
Name:LODI PHARMACY INC
Entity Type:Organization
Organization Name:LODI PHARMACY INC
Other - Org Name:LODI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-365-7788
Mailing Address - Street 1:929 S CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-4304
Mailing Address - Country:US
Mailing Address - Phone:209-365-7766
Mailing Address - Fax:209-365-7733
Practice Address - Street 1:929 S CHEROKEE LN
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-4304
Practice Address - Country:US
Practice Address - Phone:209-365-7766
Practice Address - Fax:209-365-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY499023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121631OtherPK
CAPHA499020Medicaid