Basic Information
| Provider Information | |||||||||
| NPI: | 1548266497 | ||||||||
| 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: | 223 WITMER RD | ||||||||
| Address2: | |||||||||
| City: | HORSHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190442212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776294844 | ||||||||
| FaxNumber: | 2153766939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIGAS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8004353020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | P07711 | MD | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | PP412700L | PA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 333600000X | MO0561065 | WV | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336H0001X | PA2249 | KY | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2154781 | 01 | PK | OTHER | 000572615 0002 | 05 | PA | MEDICAID |