1619604154 NPI number — HEALTHY LIFE PHARMACY LLC

Table of content: (NPI 1619604154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619604154 NPI number — HEALTHY LIFE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY LIFE PHARMACY 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:
1619604154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 W RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNE TERRE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63628-8720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-803-2352
Provider Business Mailing Address Fax Number:
888-626-5925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BISMARCK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63624-9619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-734-8588
Provider Business Practice Location Address Fax Number:
888-626-5925
Provider Enumeration Date:
08/04/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HAYNES
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
573-734-8588

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1013372952 . This is a "INDIVIDUAL PROVIDER NPI FOR LAURA HAYNES" identifier . This identifiers is of the category "OTHER".




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