Provider Demographics
NPI:1154512226
Name:LIMS SHASTA LAKE PHARMACY INC
Entity Type:Organization
Organization Name:LIMS SHASTA LAKE PHARMACY INC
Other - Org Name:LIMS SHASTA LAKE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:530-941-1179
Mailing Address - Street 1:4215 FRONT ST
Mailing Address - Street 2:STE 31
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9430
Mailing Address - Country:US
Mailing Address - Phone:530-275-2100
Mailing Address - Fax:530-275-5900
Practice Address - Street 1:4215 FRONT ST
Practice Address - Street 2:STE 31
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9430
Practice Address - Country:US
Practice Address - Phone:530-275-2100
Practice Address - Fax:530-275-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY485583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5627748OtherNCPDP PROVIDER IDENTIFICATION NUMBER