Provider Demographics
NPI:1396015103
Name:LIFEWAY PHARMACY, LLC
Entity Type:Organization
Organization Name:LIFEWAY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:SULLIVAN
Authorized Official - Last Name:DITTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:318-355-3202
Mailing Address - Street 1:1822 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4938
Mailing Address - Country:US
Mailing Address - Phone:318-323-5483
Mailing Address - Fax:318-323-5485
Practice Address - Street 1:1822 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4938
Practice Address - Country:US
Practice Address - Phone:318-323-5483
Practice Address - Fax:318-323-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017373183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty