Provider Demographics
NPI:1821205162
Name:HEALTH SERVICES AGENCY OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:HEALTH SERVICES AGENCY OUTPATIENT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HSA DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-558-7000
Mailing Address - Street 1:830 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-558-5697
Mailing Address - Fax:209-558-5631
Practice Address - Street 1:830 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-558-5697
Practice Address - Fax:209-558-5631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE20138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0513730OtherNABP NUMBER