Provider Demographics
NPI:1336652015
Name:LIFE STAR PHARMACY INC.
Entity Type:Organization
Organization Name:LIFE STAR PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-684-5010
Mailing Address - Street 1:1215 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-3301
Mailing Address - Country:US
Mailing Address - Phone:718-684-5010
Mailing Address - Fax:718-684-1011
Practice Address - Street 1:1215 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-3301
Practice Address - Country:US
Practice Address - Phone:718-684-5010
Practice Address - Fax:646-217-3682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05737628Medicaid