Provider Demographics
NPI:1154668077
Name:LIFESPAN PHARMACY, LLC
Entity Type:Organization
Organization Name:LIFESPAN PHARMACY, LLC
Other - Org Name:LIFESPAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-444-7914
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:DAVOL BUILDING
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4909
Mailing Address - Fax:401-444-2263
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:DAVOL BUILDING
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4909
Practice Address - Fax:401-444-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
RIPHA005493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110066635CMedicaid
2138499OtherPK
MA2138499OtherMEDICAID
RILI92510Medicaid