Provider Demographics
NPI:1720116122
Name:RX TRADER INC
Entity Type:Organization
Organization Name:RX TRADER INC
Other - Org Name:GLENROCK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWENR
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-551-5906
Mailing Address - Street 1:2256 COLORADO BLVD
Mailing Address - Street 2:SUITES 107 & 108
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1164
Mailing Address - Country:US
Mailing Address - Phone:323-551-5906
Mailing Address - Fax:323-551-5908
Practice Address - Street 1:2256 COLORADO BLVD
Practice Address - Street 2:SUITES 107 & 108
Practice Address - City:EAGLE ROCK
Practice Address - State:CA
Practice Address - Zip Code:90041-1164
Practice Address - Country:US
Practice Address - Phone:323-551-5906
Practice Address - Fax:323-551-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CA516093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144187OtherPK
CA6462900001Medicare NSC