1215397385 NPI number — LIFEWAY HOLDINGS LLC

Table of content: (NPI 1215397385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215397385 NPI number — LIFEWAY HOLDINGS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFEWAY HOLDINGS LLC
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:
6
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:
1215397385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 MERRITT BLVD
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
DUNDALK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-530-3731
Provider Business Mailing Address Fax Number:
443-530-3859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 MERRITT BLVD
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
DUNDALK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-530-3731
Provider Business Practice Location Address Fax Number:
443-530-3859
Provider Enumeration Date:
03/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
NGAZAL
Authorized Official First Name:
EDMOND
Authorized Official Middle Name:
ISAAC
Authorized Official Title or Position:
DIRECTOR/PHARMACIST I/C
Authorized Official Telephone Number:
443-531-3107

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: P07159 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2158496 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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