=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649655457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CDA CLINICAL PHARMACY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2015
-----------------------------------------------------
Last Update Date | 07/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11441 HEACOCK ST STE D
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92557-7907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-242-2540
-----------------------------------------------------
Fax | 951-242-1490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11441 HEACOCK ST STE D
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92557-7907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-242-2540
-----------------------------------------------------
Fax | 951-242-1490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/RPH
-----------------------------------------------------
Name | MS. AMELIA GRACE PADILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-242-2540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY 53298
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------