Provider Demographics
NPI:1982772786
Name:HOLLYWOOD PHARMACY INC
Entity Type:Organization
Organization Name:HOLLYWOOD PHARMACY INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KASPRZYK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-364-4436
Mailing Address - Street 1:1890 CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1890 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7859
Practice Address - Country:US
Practice Address - Phone:503-364-4436
Practice Address - Fax:503-364-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OR005263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131177Medicaid
OR230545Medicaid
3804627OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OR292935OtherMEDICAID DME
ORBH5418187OtherDEA #
3804627OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OR292935OtherMEDICAID DME