Provider Demographics
NPI:1477926228
Name:OLIVE CITY PHARMACY INC
Entity Type:Organization
Organization Name:OLIVE CITY PHARMACY INC
Other - Org Name:OLIVE CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-824-0954
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-0266
Mailing Address - Country:US
Mailing Address - Phone:530-514-0422
Mailing Address - Fax:
Practice Address - Street 1:954 HIGHWAY 99W
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:CA
Practice Address - Zip Code:96021-2706
Practice Address - Country:US
Practice Address - Phone:530-824-0954
Practice Address - Fax:844-618-0657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA538523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477926228Medicaid
2157817OtherPK