1730308826 NPI number — LIFESTREAM PHARMACY INC

Table of content: (NPI 1730308826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730308826 NPI number — LIFESTREAM PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESTREAM 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:
LIFESREAM RX
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:
1730308826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
847 EASTON RD
Provider Second Line Business Mailing Address:
STE 2775
Provider Business Mailing Address City Name:
WARRINGTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18976-2906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-491-0979
Provider Business Mailing Address Fax Number:
215-491-0977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
847 EASTON RD
Provider Second Line Business Practice Location Address:
STE 2775
Provider Business Practice Location Address City Name:
WARRINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18976-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-491-0979
Provider Business Practice Location Address Fax Number:
215-491-0977
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MELEKOS
Authorized Official First Name:
DEMETRIOS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-491-0979

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PP481713 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2081797 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1015654020002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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