1811468143 NPI number — LIFE PHARMACY INC

Table of content: (NPI 1811468143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811468143 NPI number — LIFE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE PHARMACY INC
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:
1811468143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5306 BENTGRASS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34211-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-302-2117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4144 LAKEWOOD RANCH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-417-5433
Provider Business Practice Location Address Fax Number:
941-896-6949
Provider Enumeration Date:
12/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SCHROEDER
Authorized Official First Name:
JEREMIAH
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
941-302-2117

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: 101880300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com