Healthcare Provider Details

I. General information

NPI: 1184016420
Provider Name (Legal Business Name): RITE AID PHARMACY STORE# 05786
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5845 E LOS ANGELES AVE
SIMI VALLEY CA
93063-4256
US

IV. Provider business mailing address

5845 E LOS ANGELES AVE N/A
SIMI VALLEY CA
93063-4256
US

V. Phone/Fax

Practice location:
  • Phone: 805-522-2029
  • Fax: 805-522-3278
Mailing address:
  • Phone: 805-522-2029
  • Fax: 805-522-3218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number41197
License Number StateCA

VIII. Authorized Official

Name: MR. SAMIR BASSILY DEIBO
Title or Position: MANAGER
Credential: PHARMACIST
Phone: 805-522-2029