1912091091 NPI number — GOOD LIFE HEALTH SERVICES INC

Table of content: (NPI 1912091091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912091091 NPI number — GOOD LIFE HEALTH SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD LIFE HEALTH SERVICES 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:
GOOD LIFE PHARMACY
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:
1912091091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 508
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUP CITY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-745-1614
Provider Business Mailing Address Fax Number:
308-745-0769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
727 O STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUP CITY
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-745-1614
Provider Business Practice Location Address Fax Number:
308-745-1614
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDREESEN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
FRANK
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
308-745-1614

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  8653 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 333600000X , with the licence number: 2344 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 2815174 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com