Provider Demographics
NPI:1366507782
Name:DRUG MART INC
Entity Type:Organization
Organization Name:DRUG MART INC
Other - Org Name:DRUG MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-536-1111
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-0159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:STE A
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-8887
Practice Address - Country:US
Practice Address - Phone:541-536-1111
Practice Address - Fax:541-536-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OR00012393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR043849Medicaid
2078266OtherPK
2078266OtherPK