Provider Demographics
NPI:1831288489
Name:OROVILLE PHARMACY
Entity Type:Organization
Organization Name:OROVILLE PHARMACY
Other - Org Name:OROVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-476-3411
Mailing Address - Street 1:PO BOX 2020
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98844-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1416 MAIN ST
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:WA
Practice Address - Zip Code:98844-9385
Practice Address - Country:US
Practice Address - Phone:509-476-3411
Practice Address - Fax:509-476-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000015483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6058101Medicaid
4905456OtherNCPDP PROVIDER IDENTIFICATION NUMBER