Provider Demographics
NPI:1902142664
Name:OCTAGON HEALTHCARE INC
Entity Type:Organization
Organization Name:OCTAGON HEALTHCARE INC
Other - Org Name:BETTER VALUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:BONJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:626-960-4723
Mailing Address - Street 1:2707 E VALLEY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-3196
Mailing Address - Country:US
Mailing Address - Phone:626-960-4723
Mailing Address - Fax:626-813-7648
Practice Address - Street 1:2707 E VALLEY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3196
Practice Address - Country:US
Practice Address - Phone:626-960-4723
Practice Address - Fax:626-813-7648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
CAPHY509663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA509660Medicaid
CAPHA509660Medicaid
6484530003Medicare NSC