1467878389 NPI number — WELL LIFE COMPOUNDING LLC

Table of content: (NPI 1467878389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467878389 NPI number — WELL LIFE COMPOUNDING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELL LIFE COMPOUNDING 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:
WELL LIFE LIBERTY LAKE 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:
1467878389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6603 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNERS FERRY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83805-8522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-267-4004
Provider Business Mailing Address Fax Number:
208-267-7405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23801 E APPLEWAY AVE
Provider Second Line Business Practice Location Address:
STE 260
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-9687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-255-7611
Provider Business Practice Location Address Fax Number:
509-755-3337
Provider Enumeration Date:
03/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER/MANAGER
Authorized Official Telephone Number:
509-755-3333

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHAR.CF.00059100 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2144734 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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