Provider Demographics
NPI:1255482709
Name:CDM PHARMACY
Entity type:Organization
Organization Name:CDM PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-673-5370
Mailing Address - Street 1:716 E BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92661-1306
Mailing Address - Country:US
Mailing Address - Phone:949-673-5370
Mailing Address - Fax:949-673-3600
Practice Address - Street 1:716 E BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92661-1306
Practice Address - Country:US
Practice Address - Phone:949-673-5370
Practice Address - Fax:949-673-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4819770001Medicare NSC