Provider Demographics
NPI:1255464871
Name:OLIVEHURST DRUG STORE INC
Entity Type:Organization
Organization Name:OLIVEHURST DRUG STORE INC
Other - Org Name:OLIVEHURST DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-743-5451
Mailing Address - Street 1:4897 OLIVEHURST AVE
Mailing Address - Street 2:PO BOX 720
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-4225
Mailing Address - Country:US
Mailing Address - Phone:530-743-5431
Mailing Address - Fax:530-743-3731
Practice Address - Street 1:4897 OLIVEHURST AVE
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-4225
Practice Address - Country:US
Practice Address - Phone:530-743-5451
Practice Address - Fax:530-743-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY488133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2066990OtherPK