Provider Demographics
NPI:1063650612
Name:LIFE SPECIALTY PHARMACY, INC
Entity Type:Organization
Organization Name:LIFE SPECIALTY PHARMACY, INC
Other - Org Name:LIFE SPECIALTY PHARMACY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOTUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-522-5683
Mailing Address - Street 1:1507 PARK CENTER DR
Mailing Address - Street 2:SUITE 1L
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1507 PARK CENTER DR
Practice Address - Street 2:SUITE 1L
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5795
Practice Address - Country:US
Practice Address - Phone:407-522-5683
Practice Address - Fax:407-522-5684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336S0011X
FLPH236993336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1042009OtherNCPDP PROVIDER IDENTIFICATION NUMBER