Provider Demographics
NPI:1114297843
Name:CROSS, CORDELL (RPH)
Entity Type:Individual
Prefix:MR
First Name:CORDELL
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 881084
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92168-1084
Mailing Address - Country:US
Mailing Address - Phone:858-268-4071
Mailing Address - Fax:
Practice Address - Street 1:5504 BALBOA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2704
Practice Address - Country:US
Practice Address - Phone:858-268-4071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30804183500000X
IA14531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist