Provider Demographics
NPI:1508299710
Name:OMEGA PHARMACY LLC
Entity Type:Organization
Organization Name:OMEGA PHARMACY LLC
Other - Org Name:OMEGA PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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 1:640 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-3365
Mailing Address - Country:US
Mailing Address - Phone:248-481-2462
Mailing Address - Fax:
Practice Address - Street 1:640 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-3365
Practice Address - Country:US
Practice Address - Phone:248-481-2462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X, 3336L0003X, 3336M0002X, 3336S0011X
MI53010101433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141640OtherPK