Provider Demographics
NPI:1366443103
Name:CIROCA CORP.
Entity Type:Organization
Organization Name:CIROCA CORP.
Other - Org Name:SUPERMARKET PHARMACY AND HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICEPRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAIRO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-679-9844
Mailing Address - Street 1:13624 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5818
Mailing Address - Country:US
Mailing Address - Phone:310-679-9844
Mailing Address - Fax:310-679-7964
Practice Address - Street 1:13624 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5818
Practice Address - Country:US
Practice Address - Phone:310-679-9844
Practice Address - Fax:310-679-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46241332B00000X, 332BP3500X, 332BX2000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0578875OtherNABP
CAPHA462410Medicaid
CA1234190001Medicare NSC