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Organization
FAIRMONT PHARMACY
Active
Organization
FAIRMONT PHARMACY
Active
Parent organization
FAIRMONT PHARMACY
Other names
FAIRMONT PHARMACY LTC
Organization subpart
Yes
Provider details
NPI number
Legal business name
FAIRMONT PHARMACY
Authorized official
DR. BEATLE THIEN-PHUOC TRAN PHARMD (CEO)
(916) 938-9556
Entity
Organization
Contact information
Practice address
1121 W VINE ST #13, LODI, CA 95240
(209) 625-8633
(209) 625-8629
Mailing address
1121 W VINE ST #13, LODI, CA 95240
(209) 625-8633
(209) 625-8629
Taxonomy
Speciality
Code
Description
License number
State
3336L0003X
Long Term Care Pharmacy
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1689063331
—
CA
01
—
PHY52074
FACILITY STATE LICENSE - CALIFORNIA
CA
Enumeration date
12/18/2023
Last updated
12/18/2023
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