Provider Demographics
NPI:1871986240
Name:CMM ENTERPRISES LLC
Entity type:Organization
Organization Name:CMM ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:IGNATIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-394-1870
Mailing Address - Street 1:2002 WATERS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2857
Mailing Address - Country:US
Mailing Address - Phone:757-287-5220
Mailing Address - Fax:
Practice Address - Street 1:5839 HARBOUR VIEW BLVD STE 102
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2657
Practice Address - Country:US
Practice Address - Phone:757-394-1870
Practice Address - Fax:757-394-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
VA02010046583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150813OtherPK
VA1871986240Medicaid