Healthcare Provider Details

I. General information

NPI: 1255482709
Provider Name (Legal Business Name): CDM PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 E BALBOA BLVD
NEWPORT BEACH CA
92661-1306
US

IV. Provider business mailing address

716 E BALBOA BLVD
NEWPORT BEACH CA
92661-1306
US

V. Phone/Fax

Practice location:
  • Phone: 949-673-5370
  • Fax: 949-673-3600
Mailing address:
  • Phone: 949-673-5370
  • Fax: 949-673-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY BRIAN FORD
Title or Position: CEO
Credential:
Phone: 949-673-5370