# CENTRAL DRUG STORE INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** SHADY COVE PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790830446
- **Authorized official:** TIMOTHY LICHLYTER (PRESIDENT)
- **Authorized official phone:** (541) 494-2616

## Contact information

- **Practice address:** 21195 HWY 62, SHADY COVE, OR 97539-9715
- **Practice address phone:** (541) 878-3151
- **Practice address fax:** (541) 878-8228
- **Mailing address:** PO BOX 700, SHADY COVE, OR 97539-0700

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | RP0000715CS | OR | Yes |

## Other

- **Enumeration date:** 01/24/2007
- **Last updated:** 08/25/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 009584 | — | OR |
| 01 | — | 3810339 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |