Provider Demographics
NPI:1528051786
Name:IVANHOE DRUG
Entity type:Organization
Organization Name:IVANHOE DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC / PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:OHANESIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:559-798-0861
Mailing Address - Street 1:33060 ROAD 159
Mailing Address - Street 2:
Mailing Address - City:IVANHOE
Mailing Address - State:CA
Mailing Address - Zip Code:93235-1235
Mailing Address - Country:US
Mailing Address - Phone:559-798-0861
Mailing Address - Fax:559-798-1815
Practice Address - Street 1:33060 ROAD 159
Practice Address - Street 2:
Practice Address - City:IVANHOE
Practice Address - State:CA
Practice Address - Zip Code:93235-1235
Practice Address - Country:US
Practice Address - Phone:559-798-0861
Practice Address - Fax:559-798-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 32581332B00000X, 332BP3500X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA 325810Medicaid