Provider Demographics
NPI:1679685663
Name:CABRILLO PHARMACY, INC.
Entity Type:Organization
Organization Name:CABRILLO PHARMACY, INC.
Other - Org Name:CABRILLO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LEARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-498-6615
Mailing Address - Street 1:146 N BRENT ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2810
Mailing Address - Country:US
Mailing Address - Phone:805-643-9939
Mailing Address - Fax:805-643-9342
Practice Address - Street 1:146 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2810
Practice Address - Country:US
Practice Address - Phone:805-643-9939
Practice Address - Fax:805-643-9342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115771OtherPK
CAPHA205810Medicaid
0549545OtherOTHER ID NUMBER-COMMERCIAL NUMBER