Provider Demographics
NPI:1306224662
Name:J & R PHARMACY P C
Entity Type:Organization
Organization Name:J & R PHARMACY P C
Other - Org Name:JC NEIGHBORHOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:951-531-8041
Mailing Address - Street 1:770 MAGNOLIA AVE
Mailing Address - Street 2:STE 1-G
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3120
Mailing Address - Country:US
Mailing Address - Phone:951-531-8041
Mailing Address - Fax:951-531-8043
Practice Address - Street 1:770 MAGNOLIA AVE STE 1G
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3121
Practice Address - Country:US
Practice Address - Phone:951-531-8041
Practice Address - Fax:951-531-8043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY555703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780273425Medicaid
CA1780273425OtherIMMUNIZATION
CA1306224662Medicaid
2151943OtherPK