1467830786 NPI number — LIVE WELL RX LLC

Table of content: (NPI 1467830786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467830786 NPI number — LIVE WELL RX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVE WELL RX 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:
LIVE WELL PHARMACY AT CHURCH LN
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:
1467830786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3811 SCHOOL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DREXEL HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19026-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-626-4549
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
727 CHURCH LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YEADON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19050-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-466-2359
Provider Business Practice Location Address Fax Number:
484-466-3650
Provider Enumeration Date:
05/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LUU
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
484-466-2359

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP482550 , 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: 2151831 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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