Provider Demographics
NPI:1942312939
Name:DOS PALOS DRUG INC
Entity type:Organization
Organization Name:DOS PALOS DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARSAMIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-392-1028
Mailing Address - Street 1:1428 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:DOS PALOS
Mailing Address - State:CA
Mailing Address - Zip Code:93620-2320
Mailing Address - Country:US
Mailing Address - Phone:209-392-1028
Mailing Address - Fax:209-392-6140
Practice Address - Street 1:1428 CENTER AVE
Practice Address - Street 2:
Practice Address - City:DOS PALOS
Practice Address - State:CA
Practice Address - Zip Code:93620-2320
Practice Address - Country:US
Practice Address - Phone:209-392-1028
Practice Address - Fax:209-392-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY456383336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942312939Medicaid
2115660OtherPK
5512810001Medicare NSC