MEDICARE: OCTAGON PHARMACEUTICAL 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	3336C0003X	Community/Retail Pharmacy	51780	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2145465	OTHER		PK

General Provider Information

NPI Number	:	1972547719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCTAGON PHARMACEUTICAL INC

Provider Business Mailing Address
First Line	:	1809 VERDUGO BLVD STE 110
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91208-1402
Country	:	US
Telephone Number	:	818-952-2108
Fax Number	:	818-952-2149

Provider Business Practice Location Address
First Line	:	1809 VERDUGO BLVD STE 110
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91208-1402
Country	:	US
Telephone Number	:	818-952-2108
Fax Number	:	818-952-2149

Authorized Official
Title or Position	:	PRESIDENT/PIC
Name	:	ELLIE YAZDI
Credential	:
Telephone Number	:	818-952-2108

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/10/2016

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