Provider Demographics
NPI:1104901131
Name:PETRA PHARMACY CORP
Entity type:Organization
Organization Name:PETRA PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RABADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-654-2791
Mailing Address - Street 1:1477 S SAN JACINTO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5105
Mailing Address - Country:US
Mailing Address - Phone:951-927-5710
Mailing Address - Fax:951-927-9834
Practice Address - Street 1:1477 S SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5105
Practice Address - Country:US
Practice Address - Phone:951-927-5710
Practice Address - Fax:951-927-9834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336H0001X
CAPHY546023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0574271OtherNCPDP #
CA1104901131OtherNPI
CAPHY54602OtherPHARMACY PERMIT
CAPHA546020Medicaid
CA1104901131OtherNPI
CA5082760001Medicare NSC