Provider Demographics
NPI:1255643995
Name:OLIVE BRANCH PHARMACY
Entity type:Organization
Organization Name:OLIVE BRANCH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REDDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALHOUSSAYNI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:213-536-4888
Mailing Address - Street 1:2070 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1235
Mailing Address - Country:US
Mailing Address - Phone:213-536-4888
Mailing Address - Fax:
Practice Address - Street 1:2070 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1235
Practice Address - Country:US
Practice Address - Phone:213-536-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-10
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50246333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255643995Medicaid
CA6721090001Medicare NSC