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NPI Code Detail

MEDICARE: MAMTA ANJALI KISSUN PHARMD, RPH

MEDICARE: MAMTA ANJALI KISSUN PHARMD, RPH
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
1183500000XPharmacist82372CA

General Provider Information

NPI Number : 1326655069
Entity Type Code : Individual
Provider Name (Legal Business Name) : MAMTA ANJALI KISSUN PHARMD, RPH
Provider Business Mailing Address
First Line : 4717 BARTRAM RUN CT
Second Line :
City : STOCKTON
State : CA
Zip : 95212-2757
Country : US
Telephone Number : 209-684-3289
Fax Number :
Provider Business Practice Location Address
First Line : 75 N HAM LN
Second Line :
City : LODI
State : CA
Zip : 95242-2700
Country : US
Telephone Number : 209-369-8575
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/27/2020
Last Update Date : 09/27/2020

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