1093968448 NPI number — LIFESPAN PHARMACY LLC

Table of content: (NPI 1093968448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093968448 NPI number — LIFESPAN PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESPAN PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SKILLED CARE OF INDIANA LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093968448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2749 EAST COVENANTER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47401-5454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-961-2326
Provider Business Mailing Address Fax Number:
317-841-0733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9900 WESTPOINT DRIVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-3358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-841-0388
Provider Business Practice Location Address Fax Number:
317-841-0733
Provider Enumeration Date:
10/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HEADLEY
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHAIRPERSON OF THE BOARD
Authorized Official Telephone Number:
812-961-2326

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336I0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 600061169B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2117622 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60006848A . This is a "PHARMACY LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200925240A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60006848B . This is a "CSR-PHARMACY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200925240 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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