Provider Demographics
NPI:1407958846
Name:GOOD LIFE LONG TERM CARE
Entity Type:Organization
Organization Name:GOOD LIFE LONG TERM CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SVOBADA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, BCPS
Authorized Official - Phone:308-728-3295
Mailing Address - Street 1:127 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:ORD
Mailing Address - State:NE
Mailing Address - Zip Code:68862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 S 16TH ST
Practice Address - Street 2:
Practice Address - City:ORD
Practice Address - State:NE
Practice Address - Zip Code:68862
Practice Address - Country:US
Practice Address - Phone:308-728-3295
Practice Address - Fax:308-728-3296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23343336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2815148OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NE=========01Medicaid
NE=========01Medicaid