1154965317 NPI number — LIVEWELL PHARMACY INC

Table of content: (NPI 1154965317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154965317 NPI number — LIVEWELL PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVEWELL PHARMACY INC
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:
LIVEWELL PHARMACY
Provider Other Organization Name Type Code:
5
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:
1154965317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1432 E GUN HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10469-3061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-843-8562
Provider Business Mailing Address Fax Number:
347-843-8565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1432 E GUN HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10469-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-843-8562
Provider Business Practice Location Address Fax Number:
347-843-8565
Provider Enumeration Date:
10/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CHAUDHARY
Authorized Official First Name:
KHALID
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
347-843-8562

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06077178 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com