Provider Demographics
NPI:1134128655
Name:MODERN DRUG INC
Entity Type:Organization
Organization Name:MODERN DRUG INC
Other - Org Name:TOUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:KIMPHI
Authorized Official - Middle Name:THI
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:559-268-2547
Mailing Address - Street 1:3250 E OLIVE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-1023
Mailing Address - Country:US
Mailing Address - Phone:559-268-2547
Mailing Address - Fax:559-268-0212
Practice Address - Street 1:3250 E OLIVE AVE
Practice Address - Street 2:STE B
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-1023
Practice Address - Country:US
Practice Address - Phone:559-268-2547
Practice Address - Fax:559-268-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY48897333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0547793OtherNCPDP
CA1134128655Medicaid
CA1134128655Medicaid