Provider Demographics
NPI:1083937395
Name:GOODLIFE PHARMACY INC
Entity Type:Organization
Organization Name:GOODLIFE PHARMACY INC
Other - Org Name:GOODLIFE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-999-8855
Mailing Address - Street 1:8903 GLADES RD STE G13
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4091
Mailing Address - Country:US
Mailing Address - Phone:561-999-8855
Mailing Address - Fax:888-688-6310
Practice Address - Street 1:8903 GLADES RD STE G13
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-4091
Practice Address - Country:US
Practice Address - Phone:561-999-8855
Practice Address - Fax:888-688-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PANP000002333600000X
FLPH244843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123482OtherPK
FL0091833000Medicaid