Provider Demographics
NPI:1417322033
Name:CCM PHARMACY LLC
Entity Type:Organization
Organization Name:CCM PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-559-1010
Mailing Address - Street 1:6821 W HILLSBOROUGH AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5003
Mailing Address - Country:US
Mailing Address - Phone:813-559-1010
Mailing Address - Fax:
Practice Address - Street 1:6821 W HILLSBOROUGH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5003
Practice Address - Country:US
Practice Address - Phone:813-559-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH295633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy