Basic Information
| Provider Information | |||||||||
| NPI: | 1457906745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORRECTIONS AND REHABILITATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CALIFORNIA REHABILITATION CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5TH AND WESTERN AVE, MODULE M, ROOM #104 | ||||||||
| Address2: | |||||||||
| City: | NORCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
| FaxNumber: | 9512732396 | ||||||||
| Practice Location | |||||||||
| Address1: | 5TH AND WESTERN AVE, MODULE M, ROOM #104 | ||||||||
| Address2: | |||||||||
| City: | NORCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
| FaxNumber: | 9512732396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THARRATT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | STATEWIDE CHIEF MEDICAL EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 9166919913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORRECTIONS AND REHABILITATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.