Provider Demographics
NPI:1154778199
Name:LIVE OAKS OCTAGON
Entity type:Organization
Organization Name:LIVE OAKS OCTAGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-729-7578
Mailing Address - Street 1:13521 STEELECROFT PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7551
Mailing Address - Country:US
Mailing Address - Phone:646-729-7578
Mailing Address - Fax:980-256-4715
Practice Address - Street 1:13521 STEELECROFT PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7551
Practice Address - Country:US
Practice Address - Phone:646-729-7578
Practice Address - Fax:980-256-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160273OtherPK