Healthcare Provider Details

I. General information

NPI: 1053412411
Provider Name (Legal Business Name): MADELEINE LORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 E UNIVERSITY DR
CARSON CA
90746-1966
US

IV. Provider business mailing address

657 E UNIVERSITY DR
CARSON CA
90746-1966
US

V. Phone/Fax

Practice location:
  • Phone: 310-323-6193
  • Fax:
Mailing address:
  • Phone: 310-323-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHY39951
License Number StateCA

VIII. Authorized Official

Name: MADELEINE LORD
Title or Position: OWNER
Credential:
Phone: 310-323-6193