Provider Demographics
NPI:1790830446
Name:CENTRAL DRUG STORE INC
Entity Type:Organization
Organization Name:CENTRAL DRUG STORE INC
Other - Org Name:SHADY COVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHLYTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-494-2616
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-0700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21195 HWY 62
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-9715
Practice Address - Country:US
Practice Address - Phone:541-878-3151
Practice Address - Fax:541-878-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP0000715CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810339OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OR009584Medicaid