Organization
FAIRMONT PHARMACY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BEATLE THIENPHUOC TRAN PHARMD (CEO/PHARMACIST)
(209) 938-9556
Entity
Organization
Contact information
Practice address
1121 W VINE ST STE 13, SUITE 13, LODI, CA 95240-5137
(209) 625-8633
(209) 625-8629
Mailing address
1121 W VINE ST STE 13, SUITE 13, LODI, CA 95240-5137
(209) 625-8633
(209) 625-8629
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
PHY52074
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PHY52074
CA BOARD OF PHARMACY
CA
Enumeration date
01/20/2015
Last updated
03/17/2015
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