Healthcare Provider Details

I. General information

NPI: 1609201730
Provider Name (Legal Business Name): CM SPECIALTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 LAFAYETTE RD STE 260
INDIANAPOLIS IN
46254-1691
US

IV. Provider business mailing address

6005 W 71ST ST
INDIANAPOLIS IN
46278-1705
US

V. Phone/Fax

Practice location:
  • Phone: 317-803-2069
  • Fax: 317-293-1836
Mailing address:
  • Phone: 317-803-3436
  • Fax: 317-803-3437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number60006341A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFF JACKSON
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 317-803-2069