MEDICARE: OCTAGON HEALTHCARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY50966	CA
3	3336C0004X	Compounding Pharmacy
4	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902142664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCTAGON HEALTHCARE INC

Provider Business Mailing Address
First Line	:	2707 E VALLEY BLVD
Second Line	:	SUITE 100
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3196
Country	:	US
Telephone Number	:	626-960-4723
Fax Number	:	626-813-7648

Provider Business Practice Location Address
First Line	:	2707 E VALLEY BLVD
Second Line	:	SUITE 100
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3196
Country	:	US
Telephone Number	:	626-960-4723
Fax Number	:	626-813-7648

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	MR. BONJUN KOO
Credential	:	RPH
Telephone Number	:	626-960-4723

Provider Enumeration Date	:	12/27/2012
Last Update Date	:	05/25/2022

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Directions to “OCTAGON HEALTHCARE INC ” Practice Location

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