Provider Demographics
NPI:1487747002
Name:OCOTILLO PHARMACY, INC.
Entity type:Organization
Organization Name:OCOTILLO PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-554-6940
Mailing Address - Street 1:196 W LEGION RD # B
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-7713
Mailing Address - Country:US
Mailing Address - Phone:760-344-4100
Mailing Address - Fax:760-344-9100
Practice Address - Street 1:196 W LEGION RD # B
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7713
Practice Address - Country:US
Practice Address - Phone:760-344-4100
Practice Address - Fax:760-344-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA465320332B00000X
CAPHA46520332BX2000X
CAPHY465323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA465320Medicaid
CA5627609OtherNCPDP
CA0447810002Medicare NSC