{
"Npi": {
"NPI": "1154512226",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LIMS SHASTA LAKE PHARMACY INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4215 FRONT ST",
"SecondLineMailingAddress": "STE 31",
"MailingAddressCityName": "SHASTA LAKE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "96019-9430",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "530-275-2100",
"MailingAddressFaxNumber": "530-275-5900",
"FirstLinePracticeLocationAddress": "4215 FRONT ST",
"SecondLinePracticeLocationAddress": "STE 31",
"PracticeLocationAddressCityName": "SHASTA LAKE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "96019-9430",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "530-275-2100",
"PracticeLocationAddressFaxNumber": "530-275-5900",
"EnumerationDate": "08/05/2007",
"LastUpdateDate": "07/01/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LIM",
"AuthorizedOfficialFirstName": "RONALD",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PHRMD",
"AuthorizedOfficialTelephoneNumber": "530-941-1179",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "PHY48558",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}