Basic Information
| Provider Information | |||||||||
| NPI: | 1538496658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KABAFUSION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KABAFUSION, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17777 CENTER COURT DR N | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004353020 | ||||||||
| FaxNumber: | 5626455396 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 MEMORIAL DR STE E | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015456202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887272323 | ||||||||
| FaxNumber: | 8889660416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASOOD | ||||||||
| AuthorizedOfficialFirstName: | SOHAIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8004353020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARM. D. | ||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336H0001X | PCN.0002241 | CT | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336S0011X | 264540 | MN | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336H0001X | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2148383 | 01 | PK | OTHER | 1538496658 | 05 | ME | MEDICAID | 110087439A | 05 | MA | MEDICAID | 1538496658 | 05 | NC | MEDICAID | 6704661 | 05 | VT | MEDICAID | 6704799 | 05 | VT | MEDICAID |