Organization
B P L P A PHARMACY CORPORATION
Active
Other names
COLES VILLAGE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
GEORGE IBRAHIM RPH (CEO)
(949) 232-4215
Entity
Organization
Contact information
Practice address
17691 SAN BERNARDINO AVE, FONTANA, CA 92335-5911
(909) 877-4224
(909) 877-1674
Mailing address
1301 PASEO GRANDE, CORONA, CA 92882-3702
(949) 232-4215
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHY50435
CA
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0507737
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
09/12/2006
Last updated
09/12/2018
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