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General NPI Number Information
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NPI Number | 1891876918
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Entity Type | Organization
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Legal Business Name | MOTHER LODE PHARMACIES, INC.
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Dates
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Enumeration Date | 10/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 64 E. SAINT CHARLES ST
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City | SAN ANDREAS
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State | CA
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Zip | 95249-0009
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Country | US
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Telephone | 209-754-3595
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Fax | 209-754-5387
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Provider Business Mailing Address
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Address Line | PO BOX 606
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City | SAN ANDREAS
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State | CA
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Zip | 95249-0606
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Country | US
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Telephone | 209-754-3595
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Fax | 209-754-5387
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RAYMOND L GUIDI
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Credential | RPH
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Telephone | 209-754-3595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 417030
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License Number State | CA
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