=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346628047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUSION IV PHARMACEUTICALS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2015
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1990 WESTWOOD BLVD # 135
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-685-8222
-----------------------------------------------------
Fax | 866-711-3106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1990 WESTWOOD BLVD # 135
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-685-8222
-----------------------------------------------------
Fax | 866-711-3106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. NAVID VAHEDI
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 877-685-8222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | PHY53726
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number | LSC100855
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------