Healthcare Provider Details

I. General information

NPI: 1114290582
Provider Name (Legal Business Name): OMEGA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W HURON ST
PONTIAC MI
48341-1425
US

IV. Provider business mailing address

420 W HURON ST
PONTIAC MI
48341-1425
US

V. Phone/Fax

Practice location:
  • Phone: 248-481-9004
  • Fax: 248-481-9168
Mailing address:
  • Phone: 248-481-9004
  • Fax: 248-481-9168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301009758
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AYODEJI ABEJIDE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 586-945-1778