Provider Demographics
NPI:1114290582
Name:OMEGA PHARMACY LLC
Entity type:Organization
Organization Name:OMEGA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AYODEJI
Authorized Official - Middle Name:
Authorized Official - Last Name:ABEJIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-945-1778
Mailing Address - Street 1:420 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1425
Mailing Address - Country:US
Mailing Address - Phone:248-481-9004
Mailing Address - Fax:248-481-9168
Practice Address - Street 1:420 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1425
Practice Address - Country:US
Practice Address - Phone:248-481-9004
Practice Address - Fax:248-481-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0002X, 3336C0004X, 3336S0011X, 333600000X, 3336L0003X, 332B00000X
MI53010097583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114290582Medicaid
2134037OtherPK