Provider Demographics
NPI:1134583735
Name:ROCKFORTH PHARMACY
Entity type:Organization
Organization Name:ROCKFORTH PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OKWUEGBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-589-5989
Mailing Address - Street 1:PO BOX 20663
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-8663
Mailing Address - Country:US
Mailing Address - Phone:510-878-7681
Mailing Address - Fax:510-969-4705
Practice Address - Street 1:14624 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2817
Practice Address - Country:US
Practice Address - Phone:510-878-7681
Practice Address - Fax:510-969-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-09
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159602OtherPK