Healthcare Provider Details

I. General information

NPI: 1306366950
Provider Name (Legal Business Name): CGM PHARMACY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BLUE OAKS BLVD STE 110
ROSEVILLE CA
95678-7038
US

IV. Provider business mailing address

1340 BLUE OAKS BLVD STE 110
ROSEVILLE CA
95678-7038
US

V. Phone/Fax

Practice location:
  • Phone: 916-771-4778
  • Fax: 916-771-0492
Mailing address:
  • Phone: 916-771-4778
  • Fax: 916-771-0492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHY55112
License Number StateCA

VIII. Authorized Official

Name: GLORY ANNE VELILLA
Title or Position: SECRETARY
Credential:
Phone: 916-771-4778