Provider Demographics
NPI:1942826235
Name:GOLDLEAF MED PHARMACY LTC LLC
Entity Type:Organization
Organization Name:GOLDLEAF MED PHARMACY LTC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MORSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-914-2269
Mailing Address - Street 1:1082 MELLON AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-6119
Mailing Address - Country:US
Mailing Address - Phone:209-473-1600
Mailing Address - Fax:209-800-1569
Practice Address - Street 1:1082 MELLON AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6119
Practice Address - Country:US
Practice Address - Phone:209-473-1600
Practice Address - Fax:209-800-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy