Provider Demographics
NPI:1609910298
Name:IVONNE DE LA ROSA
Entity Type:Organization
Organization Name:IVONNE DE LA ROSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NEGDA
Authorized Official - Middle Name:IVONNE
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:323-773-6538
Mailing Address - Street 1:6039 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-4727
Mailing Address - Country:US
Mailing Address - Phone:323-773-6538
Mailing Address - Fax:
Practice Address - Street 1:6039 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-4727
Practice Address - Country:US
Practice Address - Phone:323-773-6538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY36988333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA369880Medicaid
CA0947970001Medicare NSC