Healthcare Provider Details

I. General information

NPI: 1255032397
Provider Name (Legal Business Name): RANDI MARIA STIPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20051 N DUSTIN RD
ACAMPO CA
95220-9758
US

IV. Provider business mailing address

520 W LODI AVE
LODI CA
95240-3425
US

V. Phone/Fax

Practice location:
  • Phone: 209-598-9709
  • Fax:
Mailing address:
  • Phone: 209-368-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number124473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: