Healthcare Provider Details

I. General information

NPI: 1316236904
Provider Name (Legal Business Name): JACK LEE JAMES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 N ST
NEWMAN CA
95360-1419
US

IV. Provider business mailing address

512 STEWART RD
MODESTO CA
95356-8843
US

V. Phone/Fax

Practice location:
  • Phone: 209-862-1208
  • Fax: 209-862-2102
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: