Basic Information
Provider Information | |||||||||
NPI: | 1518971928 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OCT PHARMACY, L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACTIVE INFUSION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17777 CENTER COURT DR N STE 550 | ||||||||
Address2: |   | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907039337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004353020 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25219 DEQUINDRE RD | ||||||||
Address2: |   | ||||||||
City: | MADISON HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 480714211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483367051 | ||||||||
FaxNumber: | 2485892644 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 04/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MASOOD | ||||||||
AuthorizedOfficialFirstName: | SOHAIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8004353020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARM. D. | ||||||||
NPICertificationDate: | 04/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336H0001X |   |   | Y |   | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 540F31038 | 01 | MI | BCBSM PIN | OTHER | 470G300310 | 01 | MI | BCBSM HIT PIN | OTHER | 4620050 | 05 | MI |   | MEDICAID |