Healthcare Provider Details

I. General information

NPI: 1649655457
Provider Name (Legal Business Name): CDA CLINICAL PHARMACY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11441 HEACOCK ST STE D
MORENO VALLEY CA
92557-7907
US

IV. Provider business mailing address

11441 HEACOCK ST STE D
MORENO VALLEY CA
92557-7907
US

V. Phone/Fax

Practice location:
  • Phone: 951-242-2540
  • Fax: 951-242-1490
Mailing address:
  • Phone: 951-242-2540
  • Fax: 951-242-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY 53298
License Number StateCA

VIII. Authorized Official

Name: MS. AMELIA GRACE PADILLA
Title or Position: CEO/RPH
Credential:
Phone: 951-242-2540