=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326655069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAMTA ANJALI KISSUN PHARMD, RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2020
-----------------------------------------------------
Last Update Date | 09/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 N HAM LN
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95242-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-369-8575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4717 BARTRAM RUN CT
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95212-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-684-3289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 82372
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------