MEDICARE: LIVE OAKS OCTAGON

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	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2160273	OTHER		PK

General Provider Information

NPI Number	:	1154778199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE OAKS OCTAGON

Provider Business Mailing Address
First Line	:	13521 STEELECROFT PKWY
Second Line	:	SUITE B
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-7551
Country	:	US
Telephone Number	:	646-729-7578
Fax Number	:	980-256-4715

Provider Business Practice Location Address
First Line	:	13521 STEELECROFT PKWY
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-7551
Country	:	US
Telephone Number	:	646-729-7578
Fax Number	:	980-256-4715

Authorized Official
Title or Position	:	MANAGER
Name	:	TOM MULLEN
Credential	:
Telephone Number	:	646-729-7578

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	08/02/2016

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Directions to “LIVE OAKS OCTAGON ” Practice Location

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