Provider Demographics
NPI:1043633761
Name:LODI MEMORIAL HOSPTIAL PHARMACY WEST
Entity Type:Organization
Organization Name:LODI MEMORIAL HOSPTIAL PHARMACY WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEY
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED PHAMRACIS
Authorized Official - Phone:209-339-7439
Mailing Address - Street 1:2415 W VILNE #104
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5118
Mailing Address - Country:US
Mailing Address - Phone:209-334-3411
Mailing Address - Fax:209-333-3110
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:2415 W VINE #104
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:209-334-3411
Practice Address - Fax:209-333-3110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LODI MEMORIAL HOSPTIAL ASSOCIATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP376423336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy