Healthcare Provider Details

I. General information

NPI: 1568746410
Provider Name (Legal Business Name): SENIOR CARE PHARMACY OF THE WEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 INDUSTRIAL WAY
LODI CA
95240-3105
US

IV. Provider business mailing address

927 INDUSTRIAL WAY
LODI CA
95240-3105
US

V. Phone/Fax

Practice location:
  • Phone: 888-915-3566
  • Fax: 888-692-5991
Mailing address:
  • Phone: 888-915-3566
  • Fax: 888-692-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. GLEN KEITH ANDERSON
Title or Position: EXECUTIVE DIRECTOR
Credential: RPH
Phone: 801-410-1980