Provider Demographics
NPI:1609201730
Name:CM SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:CM SPECIALTY PHARMACY LLC
Other - Org Name:CM SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-803-2069
Mailing Address - Street 1:6005 W 71ST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1705
Mailing Address - Country:US
Mailing Address - Phone:317-803-3436
Mailing Address - Fax:317-803-3437
Practice Address - Street 1:5510 LAFAYETTE RD STE 260
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1691
Practice Address - Country:US
Practice Address - Phone:317-803-2069
Practice Address - Fax:317-293-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006341A3336C0004X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141973OtherPK