Provider Demographics
NPI:1073663431
Name:DAMERON HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:DAMERON HOSPITAL ASSOCIATION
Other - Org Name:DAMERONS LINACIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP, COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASBERG
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARM
Authorized Official - Phone:209-944-5550
Mailing Address - Street 1:420 W ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2441
Mailing Address - Country:US
Mailing Address - Phone:209-466-2954
Mailing Address - Fax:209-466-1558
Practice Address - Street 1:420 W ACACIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2441
Practice Address - Country:US
Practice Address - Phone:209-466-2954
Practice Address - Fax:209-466-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY394853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA 394850Medicaid
2077836OtherPK