Healthcare Provider Details

I. General information

NPI: 1629520150
Provider Name (Legal Business Name): CFCC SPECIALTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 S MADISON ST SUITE 1021 A AND B
TRAVERSE CITY MI
49684-2321
US

IV. Provider business mailing address

217 S. MADISON SUITE 1021 A & B
TRAVERSE CITY MI
49684
US

V. Phone/Fax

Practice location:
  • Phone: 231-392-8540
  • Fax:
Mailing address:
  • Phone: 231-392-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301011031
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PAUL KOCIEMBA
Title or Position: PHARMACY MANAGER
Credential:
Phone: 231-935-5682