Provider Demographics
NPI:1477019271
Name:SAMRA, JASPAL SINGH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASPAL
Middle Name:SINGH
Last Name:SAMRA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 INTERLAKEN DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 INTERLAKEN DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-9174
Practice Address - Country:US
Practice Address - Phone:559-355-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53352OtherCALIFORNIA STATE BOARD OF PHARMACY