Provider Demographics
NPI:1659483584
Name:COMMUNITY CARE PHARMACY
Entity Type:Organization
Organization Name:COMMUNITY CARE PHARMACY
Other - Org Name:COMMUNITY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:951-682-1063
Mailing Address - Street 1:4440 BROCKTON
Mailing Address - Street 2:STE. 400
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4005
Mailing Address - Country:US
Mailing Address - Phone:951-682-1063
Mailing Address - Fax:951-682-4500
Practice Address - Street 1:4440 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4068
Practice Address - Country:US
Practice Address - Phone:951-682-1063
Practice Address - Fax:951-682-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY358133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000457OtherPK
CAPHA358130Medicaid