Provider Demographics
NPI:1174677827
Name:ODEDRA ENTERPRISES, INC.
Entity Type:Organization
Organization Name:ODEDRA ENTERPRISES, INC.
Other - Org Name:CRYSTAL MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-588-1325
Mailing Address - Street 1:2809 OLIVE HWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6131
Mailing Address - Country:US
Mailing Address - Phone:530-533-1545
Mailing Address - Fax:530-533-5963
Practice Address - Street 1:2809 OLIVE HWY
Practice Address - Street 2:SUITE 160
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6131
Practice Address - Country:US
Practice Address - Phone:530-533-1545
Practice Address - Fax:530-533-5963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282E00000X
CAPHY535773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA461990Medicaid
2157440OtherPK
CA461990Medicaid