MEDICARE: MODERN DRUG INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy	PHY48897	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0547793	OTHER	CA	NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134128655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DRUG INC

Provider Business Mailing Address
First Line	:	3250 E OLIVE AVE
Second Line	:	STE B
City	:	FRESNO
State	:	CA
Zip	:	93702-1023
Country	:	US
Telephone Number	:	559-268-2547
Fax Number	:	559-268-0212

Provider Business Practice Location Address
First Line	:	3250 E OLIVE AVE
Second Line	:	STE B
City	:	FRESNO
State	:	CA
Zip	:	93702-1023
Country	:	US
Telephone Number	:	559-268-2547
Fax Number	:	559-268-0212

Authorized Official
Title or Position	:	PIC/TREASURER
Name	:	KIMPHI THI LE
Credential	:	RPH
Telephone Number	:	559-268-2547

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	02/24/2011

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Directions to “MODERN DRUG INC ” Practice Location

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