Provider Demographics
NPI:1326564584
Name:MAKARIOUS HEALTH CORP
Entity Type:Organization
Organization Name:MAKARIOUS HEALTH CORP
Other - Org Name:LIVE WELL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:917-544-8056
Mailing Address - Street 1:1722 UTICA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2121
Mailing Address - Country:US
Mailing Address - Phone:718-968-1600
Mailing Address - Fax:718-968-1602
Practice Address - Street 1:1722 UTICA AVE STE 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2121
Practice Address - Country:US
Practice Address - Phone:718-968-1600
Practice Address - Fax:718-968-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-19
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05171751Medicaid