Provider Demographics
NPI:1275822421
Name:GOOD LIFE PHARMACY AND WELLNESS
Entity Type:Organization
Organization Name:GOOD LIFE PHARMACY AND WELLNESS
Other - Org Name:GOOD LIFE PHARMACY & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRVAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KADDOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-782-6868
Mailing Address - Street 1:7900 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4120
Mailing Address - Country:US
Mailing Address - Phone:201-654-1862
Mailing Address - Fax:201-751-4191
Practice Address - Street 1:953 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2350
Practice Address - Country:US
Practice Address - Phone:973-782-6868
Practice Address - Fax:973-782-6870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007147003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0293041Medicaid
2131930OtherPK