Provider Demographics
NPI:1629520150
Name:CFCC SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:CFCC SPECIALTY PHARMACY LLC
Other - Org Name:CFCC SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCIEMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-5682
Mailing Address - Street 1:217 S. MADISON
Mailing Address - Street 2:SUITE 1021 A & B
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-392-8540
Mailing Address - Fax:
Practice Address - Street 1:217 S MADISON ST
Practice Address - Street 2:SUITE 1021 A AND B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2321
Practice Address - Country:US
Practice Address - Phone:231-392-8540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301011031333600000X, 3336S0011X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165924OtherPK