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General NPI Number Information
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NPI Number | 1154512226
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Entity Type | Organization
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Legal Business Name | LIMS SHASTA LAKE PHARMACY INC
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 07/01/2009
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Provider Practice Location Address
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Address Line | 4215 FRONT ST STE 31
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City | SHASTA LAKE
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State | CA
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Zip | 96019-9430
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Country | US
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Telephone | 530-275-2100
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Fax | 530-275-5900
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Provider Business Mailing Address
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Address Line | 4215 FRONT ST STE 31
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City | SHASTA LAKE
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State | CA
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Zip | 96019-9430
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Country | US
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Telephone | 530-275-2100
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Fax | 530-275-5900
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Authorized Official
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Title or Position | PRESIDENT
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Name | RONALD LIM
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Credential | PHRMD
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Telephone | 530-941-1179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY48558
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License Number State | CA
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