Provider Demographics
NPI:1467576538
Name:CRANDALL'S MEDICAL PHARMACY
Entity Type:Organization
Organization Name:CRANDALL'S MEDICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:IQAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:909-985-6814
Mailing Address - Street 1:360 E 7TH ST STE F
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6701
Mailing Address - Country:US
Mailing Address - Phone:909-985-6814
Mailing Address - Fax:909-985-9087
Practice Address - Street 1:360 E 7TH ST STE F
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6701
Practice Address - Country:US
Practice Address - Phone:909-985-6814
Practice Address - Fax:909-985-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY4417043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA417040Medicaid