Healthcare Provider Details

I. General information

NPI: 1255464871
Provider Name (Legal Business Name): OLIVEHURST DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4897 OLIVEHURST AVE
OLIVEHURST CA
95961-4225
US

IV. Provider business mailing address

4897 OLIVEHURST AVE PO BOX 720
OLIVEHURST CA
95961-4225
US

V. Phone/Fax

Practice location:
  • Phone: 530-743-5451
  • Fax: 530-743-3713
Mailing address:
  • Phone: 530-743-5431
  • Fax: 530-743-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY48813
License Number StateCA

VIII. Authorized Official

Name: HECTOR CAMACHO
Title or Position: OWNER/PIC
Credential: RPH
Phone: 530-743-5451