Provider Demographics
NPI:1619910494
Name:OLIVE PHARMACY, INC
Entity Type:Organization
Organization Name:OLIVE PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:THANE
Authorized Official - Last Name:HARLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-533-3103
Mailing Address - Street 1:2721 OLIVE HWY
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6115
Mailing Address - Country:US
Mailing Address - Phone:530-533-3103
Mailing Address - Fax:530-533-3962
Practice Address - Street 1:2721 OLIVE HWY
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6115
Practice Address - Country:US
Practice Address - Phone:530-533-3103
Practice Address - Fax:530-533-3962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY451573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA451570Medicaid
CA4713290001Medicare NSC