1124595558 NPI number — LIFE TREE PHARMACY SERVICES INCORPORATED

Table of content: (NPI 1124595558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124595558 NPI number — LIFE TREE PHARMACY SERVICES INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE TREE PHARMACY SERVICES INCORPORATED
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:
Provider Other Organization Name Type Code:
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:
1124595558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 BLUE HERON DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGEVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19426-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-489-6640
Provider Business Mailing Address Fax Number:
610-489-6645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 PARK CENTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROUSSARD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70518-3605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-489-6640
Provider Business Practice Location Address Fax Number:
610-489-6645
Provider Enumeration Date:
10/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TAGLIANETTI
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
610-489-6640

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; 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: "Y" .

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





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