Provider Demographics
NPI:1144392226
Name:SUBURBAN DRUG CO A CORP
Entity Type:Organization
Organization Name:SUBURBAN DRUG CO A CORP
Other - Org Name:LOS COYOTES DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:562-420-1480
Mailing Address - Street 1:10572 CALLE LEE STE 138
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-8541
Mailing Address - Country:US
Mailing Address - Phone:562-420-1480
Mailing Address - Fax:866-859-1508
Practice Address - Street 1:10572 CALLE LEE STE 138
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-8541
Practice Address - Country:US
Practice Address - Phone:562-420-1480
Practice Address - Fax:866-859-1508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY558143336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0510190OtherNCPDP#
CAPHY55814Medicaid
CA1077290001Medicare ID - Type Unspecified