Provider Demographics
NPI:1790106458
Name:CPM PHARMACY LLC
Entity Type:Organization
Organization Name:CPM PHARMACY LLC
Other - Org Name:ADVANCED RX PHARMACY 034
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATI
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-621-2900
Mailing Address - Street 1:C/O ADVANCED RX MANAGEMENT
Mailing Address - Street 2:4683 CHABOT DRIVE, SUITE 200
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588
Mailing Address - Country:US
Mailing Address - Phone:925-621-2909
Mailing Address - Fax:904-389-1082
Practice Address - Street 1:3870 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1110
Practice Address - Country:US
Practice Address - Phone:678-564-2233
Practice Address - Fax:678-401-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0099763336C0003X, 3336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149245OtherPK