Provider Demographics
NPI:1104694371
Name:FAIRMONT PHARMACY
Entity type:Organization
Organization Name:FAIRMONT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BEATLE
Authorized Official - Middle Name:THIEN-PHUOC
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-938-9556
Mailing Address - Street 1:1121 W VINE ST #13
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-625-8633
Mailing Address - Fax:209-625-8629
Practice Address - Street 1:1121 W VINE ST #13
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-625-8633
Practice Address - Fax:209-625-8629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRMONT PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689063331Medicaid
CAPHY52074OtherFACILITY STATE LICENSE - CALIFORNIA