Healthcare Provider Details

I. General information

NPI: 1104901131
Provider Name (Legal Business Name): PETRA PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 S SAN JACINTO AVE
SAN JACINTO CA
92583-5105
US

IV. Provider business mailing address

1477 S SAN JACINTO AVE
SAN JACINTO CA
92583-5105
US

V. Phone/Fax

Practice location:
  • Phone: 951-927-5710
  • Fax: 951-927-9834
Mailing address:
  • Phone: 951-927-5710
  • Fax: 951-927-9834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY54602
License Number StateCA

VIII. Authorized Official

Name: MS. LINDA RABADI
Title or Position: CFO
Credential:
Phone: 951-654-2791