MEDICARE: OLIVE TREE PHARMACY, CO.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	PH00004369	NM

General Provider Information

NPI Number	:	1053850784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE TREE PHARMACY, CO.

Provider Business Mailing Address
First Line	:	1920 WESTSIDE BLVD SE STE B
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-4893
Country	:	US
Telephone Number	:	505-738-3328
Fax Number	:

Provider Business Practice Location Address
First Line	:	1920 WESTSIDE BLVD SE STE B
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-4893
Country	:	US
Telephone Number	:	505-738-3328
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND OWNER
Name	:	NDIDIAMAKA OKPAREKE
Credential	:	PHARMD
Telephone Number	:	706-509-1012

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/14/2017

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