Provider Demographics
NPI:1295869733
Name:KBC PHARMACY INC
Entity type:Organization
Organization Name:KBC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:909-338-1875
Mailing Address - Street 1:580 FOREST SHADE RD PO BOX 2220
Mailing Address - Street 2:STE 7
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-2220
Mailing Address - Country:US
Mailing Address - Phone:909-338-1875
Mailing Address - Fax:909-338-1876
Practice Address - Street 1:580 FOREST SHADE RD
Practice Address - Street 2:STE 7
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325-9274
Practice Address - Country:US
Practice Address - Phone:909-338-1875
Practice Address - Fax:909-338-1876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154295OtherPK
CA1295869733Medicaid