# FAIRMONT PHARMACY

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** FAIRMONT PHARMACY
- **Other names:** FAIRMONT PHARMACY LTC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1104694371
- **Legal business name:** FAIRMONT PHARMACY
- **Authorized official:** DR. BEATLE THIEN-PHUOC TRAN PHARMD (CEO)
- **Authorized official phone:** (916) 938-9556

## Contact information

- **Practice address:** 1121 W VINE ST \#13, LODI, CA 95240
- **Practice address phone:** (209) 625-8633
- **Practice address fax:** (209) 625-8629
- **Mailing address:** 1121 W VINE ST \#13, LODI, CA 95240
- **Mailing address phone:** (209) 625-8633
- **Mailing address fax:** (209) 625-8629

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336L0003X | Long Term Care Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 12/18/2023
- **Last updated:** 12/18/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1689063331 | — | CA |
| 01 | — | PHY52074 | FACILITY STATE LICENSE - CALIFORNIA | CA |