Provider Demographics
NPI:1275673923
Name:LIFE PHAMACY INC
Entity Type:Organization
Organization Name:LIFE PHAMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ELAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-438-1421
Mailing Address - Street 1:4301 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-1429
Mailing Address - Country:US
Mailing Address - Phone:718-438-1421
Mailing Address - Fax:718-438-1483
Practice Address - Street 1:4301 14TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-1429
Practice Address - Country:US
Practice Address - Phone:718-438-1421
Practice Address - Fax:718-438-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047043-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02473958Medicaid
NY5118200001Medicare ID - Type Unspecified