1255652210 NPI number — LIFE RX INC

Table of content: (NPI 1255652210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255652210 NPI number — LIFE RX INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE RX 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:
SCOTT'S THRIFTY WHITE DRUG
Provider Other Organization Name Type Code:
3
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:
1255652210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
629 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE WITT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52742-1635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-659-5042
Provider Business Mailing Address Fax Number:
563-659-5044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DE WITT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52742-1635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-659-5042
Provider Business Practice Location Address Fax Number:
563-659-5044
Provider Enumeration Date:
06/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
563-659-5042

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 280 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0001270 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2125509 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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