Healthcare Provider Details

I. General information

NPI: 1871986240
Provider Name (Legal Business Name): CMM ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5839 HARBOUR VIEW BLVD STE 102
SUFFOLK VA
23435-2657
US

IV. Provider business mailing address

2002 WATERS EDGE LN
SUFFOLK VA
23435-2857
US

V. Phone/Fax

Practice location:
  • Phone: 757-394-1870
  • Fax: 757-394-1873
Mailing address:
  • Phone: 757-287-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201004658
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: IGNATIUS COMBRINK
Title or Position: OWNER, PIC, AO
Credential:
Phone: 757-394-1870