Provider Demographics
NPI:1568803260
Name:SHASTA LAKE DRUG STORE INC
Entity Type:Organization
Organization Name:SHASTA LAKE DRUG STORE INC
Other - Org Name:SHASTA LAKE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-339-1445
Mailing Address - Street 1:PO BOX 991179
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-1179
Mailing Address - Country:US
Mailing Address - Phone:530-275-2700
Mailing Address - Fax:530-275-2800
Practice Address - Street 1:4222 SHASTA DAM BLVD
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9422
Practice Address - Country:US
Practice Address - Phone:530-275-2700
Practice Address - Fax:530-275-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA512773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138099OtherPK
CAPHA512770Medicaid