Organization
CENTRAL DRUG STORE INC
Active
Other names
SHADY COVE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
TIMOTHY LICHLYTER (PRESIDENT)
(541) 494-2616
Entity
Organization
Contact information
Practice address
21195 HWY 62, SHADY COVE, OR 97539-9715
(541) 878-3151
(541) 878-8228
Mailing address
PO BOX 700, SHADY COVE, OR 97539-0700
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
RP0000715CS
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009584
—
OR
01
—
3810339
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
01/24/2007
Last updated
08/25/2010
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