NPIMap

Organization Active NPI

Central Drug Store Inc

Doing business as Shady Cove Pharmacy

  • Community/Retail Pharmacy
  • Shady Cove, OR
National Provider Identifier
1790830446
Registry record updated Aug 25, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
RP0000715CS Issued in OR
Legal business name
CENTRAL DRUG STORE INC
Doing business as
Shady Cove Pharmacy
Practice address
21195 Hwy 62
Shady Cove, OR 97539-9715
Phone
(541) 878-3151
Fax
(541) 878-8228
NPI assigned
Jan 24, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 25, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy Lichlyter
Title
President
Phone
(541) 494-2616

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X RP0000715CS OR Primary

Addresses

Primary practice location

21195 Hwy 62
Shady Cove, OR 97539-9715

Mailing address

PO Box 700
Shady Cove, OR 97539-0700

Other identifiers 2

IdentifierTypeStateIssuer
3810339OtherNCPDP PROVIDER IDENTIFICATION NUMBER
009584MedicaidOR

Other names 1

  • SHADY COVE PHARMACY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051117000213 OR Part B Supplier - Mass Immunization (Roster Biller Only) 6608895735 1 other NPI on this enrollment
Practice locations: Medford, OR; Shady Cove, OR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Black Oak Home Medical3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

21195 Highway 62
Shady Cove, OR 97539
Phone (541) 878-3151

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169596800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1282694400000",
    "number": "1790830446",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 700",
            "city": "SHADY COVE",
            "state": "OR",
            "postal_code": "975390700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21195 HWY 62",
            "city": "SHADY COVE",
            "state": "OR",
            "postal_code": "975399715",
            "telephone_number": "541-878-3151",
            "fax_number": "541-878-8228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRAL DRUG STORE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-24",
        "last_updated": "2010-08-25",
        "status": "A",
        "authorized_official_last_name": "LICHLYTER",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "541-494-2616"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OR",
            "license": "RP0000715CS",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "3810339",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "009584",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SHADY COVE PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shady Cove, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 25, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.