Provider Demographics
NPI:1639669005
Name:CC PHARMACY 3 LLC
Entity Type:Organization
Organization Name:CC PHARMACY 3 LLC
Other - Org Name:CC PHARMACY 3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:737-202-4101
Mailing Address - Street 1:3000 JOE DIMAGGIO BLVD
Mailing Address - Street 2:SUITE #57
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-3922
Mailing Address - Country:US
Mailing Address - Phone:737-202-4101
Mailing Address - Fax:737-202-4104
Practice Address - Street 1:3000 JOE DIMAGGIO BLVD STE 57
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-3996
Practice Address - Country:US
Practice Address - Phone:737-202-4101
Practice Address - Fax:737-202-4104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-11
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX313123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177684OtherPK