Provider Demographics
NPI:1831131655
Name:OAKDALE PHARMACY INC
Entity Type:Organization
Organization Name:OAKDALE PHARMACY INC
Other - Org Name:OAKDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:818-788-0770
Mailing Address - Street 1:5400 BALBOA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1598
Mailing Address - Country:US
Mailing Address - Phone:818-788-0770
Mailing Address - Fax:818-788-0550
Practice Address - Street 1:5400 BALBOA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1598
Practice Address - Country:US
Practice Address - Phone:818-788-0770
Practice Address - Fax:818-788-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY394283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115759OtherPK
CAPHY212960Medicaid
CA1101700001Medicaid
CAPHY212960Medicaid