Provider Demographics
NPI:1033202460
Name:CBC PROFESSIONAL PHARMACY INC
Entity Type:Organization
Organization Name:CBC PROFESSIONAL PHARMACY INC
Other - Org Name:CBC ROSE CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-982-4843
Mailing Address - Street 1:1932 ERVILLA PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3019
Mailing Address - Country:US
Mailing Address - Phone:909-629-2823
Mailing Address - Fax:909-629-2891
Practice Address - Street 1:420 W ROWLAND ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2943
Practice Address - Country:US
Practice Address - Phone:626-966-9888
Practice Address - Fax:626-966-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY487733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1989164OtherPK
CAPHA487730Medicaid
1989164OtherPK