Provider Demographics
NPI:1568746410
Name:SENIOR CARE PHARMACY OF THE WEST, LLC
Entity Type:Organization
Organization Name:SENIOR CARE PHARMACY OF THE WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-410-1980
Mailing Address - Street 1:927 INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3105
Mailing Address - Country:US
Mailing Address - Phone:888-915-3566
Mailing Address - Fax:888-692-5991
Practice Address - Street 1:927 INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3105
Practice Address - Country:US
Practice Address - Phone:888-915-3566
Practice Address - Fax:888-692-5991
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENIOR CARE PHARMACY OF THE WEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy