Healthcare Provider Details

I. General information

NPI: 1760455711
Provider Name (Legal Business Name): MODERN DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3044 TULARE ST
FRESNO CA
93721
US

IV. Provider business mailing address

3044 TULARE ST
FRESNO CA
93721
US

V. Phone/Fax

Practice location:
  • Phone: 559-266-0701
  • Fax: 559-266-2438
Mailing address:
  • Phone: 559-266-0701
  • Fax: 559-266-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY43219
License Number StateCA

VIII. Authorized Official

Name: CHAN B LUONG
Title or Position: PRESIDENT
Credential: RPH
Phone: 559-266-0701