Provider Demographics
NPI:1366657488
Name:REBEL DISTRIBUTORS
Entity Type:Organization
Organization Name:REBEL DISTRIBUTORS
Other - Org Name:PHYSICIAN PARTNER/PHARMACY PARTNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DESTRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SETSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-732-3579
Mailing Address - Street 1:3607 OLD CONEJO RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2123
Mailing Address - Country:US
Mailing Address - Phone:805-214-0900
Mailing Address - Fax:805-214-0950
Practice Address - Street 1:3607 OLD CONEJO RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-2123
Practice Address - Country:US
Practice Address - Phone:805-214-0900
Practice Address - Fax:805-214-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWLS3004332900000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies