Provider Demographics
NPI:1982665428
Name:OSBURN DRUG CO
Entity Type:Organization
Organization Name:OSBURN DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAVIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-556-1139
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:OSBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83849-2170
Mailing Address - Country:US
Mailing Address - Phone:208-556-1139
Mailing Address - Fax:208-556-7311
Practice Address - Street 1:805 E MULLAN AVE.
Practice Address - Street 2:
Practice Address - City:OSBURN
Practice Address - State:ID
Practice Address - Zip Code:83849-2170
Practice Address - Country:US
Practice Address - Phone:208-556-1139
Practice Address - Fax:208-556-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID245CP332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002450400Medicaid
ID002450400Medicaid