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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