Provider Demographics
NPI:1780269175
Name:OLIVE TREE HEALTHCARE LLC
Entity type:Organization
Organization Name:OLIVE TREE HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADIGUN
Authorized Official - Middle Name:OLATUBOSUN
Authorized Official - Last Name:ITABIYI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-257-3105
Mailing Address - Street 1:253 S 60TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3844
Mailing Address - Country:US
Mailing Address - Phone:610-257-3105
Mailing Address - Fax:610-257-3104
Practice Address - Street 1:253 S 60TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3844
Practice Address - Country:US
Practice Address - Phone:610-257-3105
Practice Address - Fax:610-257-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-16
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103935262-0001Medicaid