Provider Demographics
NPI:1417500109
Name:LOPEZ, ALEXANDRA JO
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JO
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W BRIGGSMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3791
Mailing Address - Country:US
Mailing Address - Phone:209-521-5713
Mailing Address - Fax:
Practice Address - Street 1:2020 W BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3791
Practice Address - Country:US
Practice Address - Phone:209-521-5713
Practice Address - Fax:209-521-6932
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist