Provider Demographics
NPI:1720140346
Name:CCMT, LLC
Entity type:Organization
Organization Name:CCMT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SURMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-326-4759
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:200 EAST PALMETTO
Mailing Address - City:PLAIN DEALING
Mailing Address - State:LA
Mailing Address - Zip Code:71064-0216
Mailing Address - Country:US
Mailing Address - Phone:318-326-4759
Mailing Address - Fax:318-326-7383
Practice Address - Street 1:200 EAST PALMETTO
Practice Address - Street 2:
Practice Address - City:PLAIN DEALING
Practice Address - State:LA
Practice Address - Zip Code:71064
Practice Address - Country:US
Practice Address - Phone:318-326-4759
Practice Address - Fax:318-326-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2205684Medicaid