Provider Demographics
NPI:1093968448
Name:LIFESPAN PHARMACY LLC
Entity Type:Organization
Organization Name:LIFESPAN PHARMACY LLC
Other - Org Name:SKILLED CARE OF INDIANA LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHAIRPERSON OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-961-2326
Mailing Address - Street 1:2749 EAST COVENANTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5454
Mailing Address - Country:US
Mailing Address - Phone:812-961-2326
Mailing Address - Fax:317-841-0733
Practice Address - Street 1:9900 WESTPOINT DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3358
Practice Address - Country:US
Practice Address - Phone:317-841-0388
Practice Address - Fax:317-841-0733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X, 3336L0003X
IN600061169B3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117622OtherPK
IN60006848AOtherPHARMACY LICENSE
IN200925240AMedicaid
IN60006848BOtherCSR-PHARMACY
IN200925240Medicaid