Active NPI
Mamta Anjali Kissun, PHARMD, RPH
- Pharmacist
- Lodi, CA
National Provider Identifier
1326655069
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 82372
- Practice address
- 75 N Ham LN
Lodi, CA 95242-2700 - Phone
- (209) 369-8575
- NPI assigned
- Sep 27, 2020
- Last updated
- Sep 27, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 82372 | CA | Primary |
Addresses
Primary practice location
75 N Ham LN
Lodi, CA 95242-2700
Mailing address
4717 Bartram Run CT
Stockton, CA 95212-2757
Phone (209) 684-3289
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Pharmacy, Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 82372 | CA | MD | Pediatric Adolescent Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1601164800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1601164800000",
"number": "1326655069",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4717 BARTRAM RUN CT",
"city": "STOCKTON",
"state": "CA",
"postal_code": "952122757",
"telephone_number": "209-684-3289"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "75 N HAM LN",
"city": "LODI",
"state": "CA",
"postal_code": "952422700",
"telephone_number": "209-369-8575"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KISSUN",
"first_name": "MAMTA",
"middle_name": "ANJALI",
"credential": "PHARMD, RPH",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-09-27",
"last_updated": "2020-09-27",
"certification_date": "2020-09-27",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "CA",
"license": "82372",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}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 Sep 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.