=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184205122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LMD SAN DIEGO PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2021
-----------------------------------------------------
Last Update Date | 04/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 S MAGNOLIA AVE STE 102
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-5221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-606-0677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2229 RUNABOUT PL
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92019-4250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-606-0677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/PRESIDENT
-----------------------------------------------------
Name | GHASSAN AZEEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-606-0677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------