Provider Demographics
NPI:1760455711
Name:MODERN DRUG INC
Entity Type:Organization
Organization Name:MODERN DRUG INC
Other - Org Name:MODERN DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LUONG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:559-266-0701
Mailing Address - Street 1:3044 TULARE ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721
Mailing Address - Country:US
Mailing Address - Phone:559-266-0701
Mailing Address - Fax:559-266-2438
Practice Address - Street 1:3044 TULARE ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-266-0701
Practice Address - Fax:559-266-2438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43219333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA432190Medicaid
6305080001Medicare NSC