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
BEATLE THIEN-PHUOC TRAN PHARMD (CEO/PHARMD)
(209) 938-9556
Entity
Organization
Contact information
Practice address
1121 W VINE ST STE 13, LODI, CA 95240-5137
(209) 625-8633
(209) 625-8629
Mailing address
1121 W VINE ST STE 13, LODI, CA 95240-5137
(209) 938-9556
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1689063331
—
CA
01
—
PHY52074
FACILITY STATE PHARMACY LICENSE - CALIFORNIA
CA
Enumeration date
12/18/2023
Last updated
12/18/2023
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