Provider Demographics
NPI:1225378771
Name:LIVE GOOD PHARMACY INC
Entity Type:Organization
Organization Name:LIVE GOOD PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:NGOZI
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBASIONWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-221-9300
Mailing Address - Street 1:PO BOX 250018
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-0018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-3508
Practice Address - Country:US
Practice Address - Phone:718-221-9300
Practice Address - Fax:718-221-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0317323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6729060001Medicare NSC