Healthcare Provider Details

I. General information

NPI: 1821205162
Provider Name (Legal Business Name): HEALTH SERVICES AGENCY OUTPATIENT PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SCENIC DR
MODESTO CA
95350-6131
US

IV. Provider business mailing address

830 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-5697
  • Fax: 209-558-5631
Mailing address:
  • Phone: 209-558-5697
  • Fax: 209-558-5631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHE20138
License Number StateCA

VIII. Authorized Official

Name: MARY ANN LEE
Title or Position: HSA DIRECTOR
Credential:
Phone: 209-558-7000