Provider Demographics
NPI:1346892403
Name:CCDE, LLC
Entity Type:Organization
Organization Name:CCDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DAINE
Authorized Official - Last Name:CURNUTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:702-960-8640
Mailing Address - Street 1:PO BOX 6380
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89041-6380
Mailing Address - Country:US
Mailing Address - Phone:702-960-8640
Mailing Address - Fax:
Practice Address - Street 1:2780 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5399
Practice Address - Country:US
Practice Address - Phone:702-960-8640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy