Provider Demographics
NPI:1851473656
Name:OUTDOOR WORLD INC
Entity Type:Organization
Organization Name:OUTDOOR WORLD INC
Other - Org Name:SERVICE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:541-476-8224
Mailing Address - Street 1:1204 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1254
Mailing Address - Country:US
Mailing Address - Phone:541-476-8224
Mailing Address - Fax:541-476-4132
Practice Address - Street 1:1204 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1254
Practice Address - Country:US
Practice Address - Phone:541-476-8224
Practice Address - Fax:541-476-4132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP-00002173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR190751Medicaid
2077236OtherPK
4990480001Medicare NSC