Provider Demographics
NPI:1548615230
Name:DEOL, MANDEEP
Entity Type:Individual
Prefix:
First Name:MANDEEP
Middle Name:
Last Name:DEOL
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 1:10360 BRIDGEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7280
Mailing Address - Country:US
Mailing Address - Phone:209-603-0771
Mailing Address - Fax:
Practice Address - Street 1:4601 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9718
Practice Address - Country:US
Practice Address - Phone:209-735-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 691491835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care