Healthcare Provider Details

I. General information

NPI: 1154778199
Provider Name (Legal Business Name): LIVE OAKS OCTAGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13521 STEELECROFT PKWY
CHARLOTTE NC
28278-7551
US

IV. Provider business mailing address

13521 STEELECROFT PKWY SUITE B
CHARLOTTE NC
28278-7551
US

V. Phone/Fax

Practice location:
  • Phone: 646-729-7578
  • Fax: 980-256-4715
Mailing address:
  • Phone: 646-729-7578
  • Fax: 980-256-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TOM MULLEN
Title or Position: MANAGER
Credential:
Phone: 646-729-7578