Active NPI
Fairmont Pharmacy
- Long Term Care Pharmacy
- Lodi, CA
National Provider Identifier
1104694371
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Long Term Care Pharmacy
- Legal business name
- FAIRMONT PHARMACY
- Practice address
- 1121 W Vine St #13
Lodi, CA 95240 - Phone
- (209) 625-8633
- Fax
- (209) 625-8629
- NPI assigned
- Dec 18, 2023
- Organization subpart
- Yes
- Parent organization
- FAIRMONT PHARMACY
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Beatle Thien-Phuoc Tran, PHARMD
- Title
- Ceo
- Phone
- (916) 938-9556
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Long Term Care Pharmacy | 3336L0003X | Primary |
Addresses
Primary practice location
1121 W Vine St #13
Lodi, CA 95240
Mailing address
1121 W Vine St #13
Lodi, CA 95240
Phone (209) 625-8633
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1689063331 | Medicaid | CA | |
| PHY52074 | Other | CA | FACILITY STATE LICENSE - CALIFORNIA |
Other names 1
- FAIRMONT PHARMACY LTC
National Provider Directory
National Provider Directory- Tax ID family
- Fairmont Pharmacy
- Part of
- Fairmont Pharmacy
Other organizations with this tax ID 2
Organizations that report the same tax identification number in the National Provider Directory.
-
- Community/Retail Pharmacy
- Lodi, CA
- NPI 1689063331
-
- Community/Retail Pharmacy
- Lodi, CA
- NPI 1689442956
Locations
1121 W Vine St
Ste 13
Lodi, CA 95240
Phone (209) 625-8633
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1702857600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1702857600000",
"number": "1104694371",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1121 W VINE ST #13",
"city": "LODI",
"state": "CA",
"postal_code": "95240",
"telephone_number": "209-625-8633",
"fax_number": "209-625-8629"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1121 W VINE ST #13",
"city": "LODI",
"state": "CA",
"postal_code": "95240",
"telephone_number": "209-625-8633",
"fax_number": "209-625-8629"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "FAIRMONT PHARMACY",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "FAIRMONT PHARMACY",
"enumeration_date": "2023-12-18",
"last_updated": "2023-12-18",
"certification_date": "2023-12-16",
"status": "A",
"authorized_official_last_name": "TRAN",
"authorized_official_first_name": "BEATLE",
"authorized_official_middle_name": "THIEN-PHUOC",
"authorized_official_title_or_position": "CEO",
"authorized_official_telephone_number": "916-938-9556",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "PHARMD"
},
"taxonomies": [
{
"code": "3336L0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Long Term Care Pharmacy",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1689063331",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FACILITY STATE LICENSE - CALIFORNIA",
"identifier": "PHY52074",
"state": "CA"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "FAIRMONT PHARMACY LTC",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Lodi, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.