Provider Demographics
NPI:1790013530
Name:ONCOMED PHARMACEUTICAL SERVICES OF MA, LLC
Entity Type:Organization
Organization Name:ONCOMED PHARMACEUTICAL SERVICES OF MA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FALKENRATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-662-6633
Mailing Address - Street 1:13410 EASTPOINT CENTRE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4160
Mailing Address - Country:US
Mailing Address - Phone:877-662-6633
Mailing Address - Fax:502-849-0643
Practice Address - Street 1:335 BEAR HILL RD STE 2100
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1006
Practice Address - Country:US
Practice Address - Phone:877-662-6633
Practice Address - Fax:877-662-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-04
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
MADS897023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110084520Medicaid
MA6321140001Medicare NSC