Provider Demographics
NPI:1689442956
Name:FAIRMONT PHARMACY
Entity Type:Organization
Organization Name:FAIRMONT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:BEATLE
Authorized Official - Middle Name:THIEN-PHUOC
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:209-938-9556
Mailing Address - Street 1:1121 W VINE ST STE 13
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5137
Mailing Address - Country:US
Mailing Address - Phone:209-938-9556
Mailing Address - Fax:
Practice Address - Street 1:1121 W VINE ST STE 13
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5137
Practice Address - Country:US
Practice Address - Phone:209-625-8633
Practice Address - Fax:209-625-8629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRMONT PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689063331Medicaid
CAPHY52074OtherFACILITY STATE PHARMACY LICENSE - CALIFORNIA