Provider Demographics
NPI:1215397385
Name:LIFEWAY HOLDINGS LLC
Entity Type:Organization
Organization Name:LIFEWAY HOLDINGS LLC
Other - Org Name:LIFEWAY PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/PHARMACIST I/C
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:NGAZAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-531-3107
Mailing Address - Street 1:700 MERRITT BLVD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222
Mailing Address - Country:US
Mailing Address - Phone:443-530-3731
Mailing Address - Fax:443-530-3859
Practice Address - Street 1:700 MERRITT BLVD
Practice Address - Street 2:SUITE 1A
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222
Practice Address - Country:US
Practice Address - Phone:443-530-3731
Practice Address - Fax:443-530-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP071593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158496OtherPK