Provider Demographics
NPI:1912028465
Name:CROCKER DRUG INC
Entity Type:Organization
Organization Name:CROCKER DRUG INC
Other - Org Name:CROCKER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:FERN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-670-2316
Mailing Address - Street 1:502 EUCLID AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2994
Mailing Address - Country:US
Mailing Address - Phone:619-267-8159
Mailing Address - Fax:619-267-8167
Practice Address - Street 1:502 EUCLID AVE
Practice Address - Street 2:STE 100
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2994
Practice Address - Country:US
Practice Address - Phone:619-267-8159
Practice Address - Fax:619-267-8167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA200493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0538528OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA200490Medicaid
1055220001Medicare NSC