Provider Demographics
NPI:1285619460
Name:LODI DRUG COMPANY, INC
Entity type:Organization
Organization Name:LODI DRUG COMPANY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SPANOS
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-339-8624
Mailing Address - Street 1:115 LAKEWOOD MALL
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-2963
Mailing Address - Country:US
Mailing Address - Phone:209-368-6636
Mailing Address - Fax:
Practice Address - Street 1:115 LAKEWOOD MALL
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-2963
Practice Address - Country:US
Practice Address - Phone:209-368-6636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY20652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA206520Medicaid
CAPHA206520Medicare ID - Type Unspecified
CA0510087Medicare UPIN