Provider Demographics
NPI:1184016420
Name:RITE AID PHARMACY STORE# 05786
Entity Type:Organization
Organization Name:RITE AID PHARMACY STORE# 05786
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:BASSILY
Authorized Official - Last Name:DEIBO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:805-522-2029
Mailing Address - Street 1:5845 E LOS ANGELES AVE
Mailing Address - Street 2:N/A
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4256
Mailing Address - Country:US
Mailing Address - Phone:805-522-2029
Mailing Address - Fax:805-522-3218
Practice Address - Street 1:5845 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-4256
Practice Address - Country:US
Practice Address - Phone:805-522-2029
Practice Address - Fax:805-522-3278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41197333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy