Provider Demographics
NPI:1437672797
Name:LIFE CHANGE RX LLC
Entity Type:Organization
Organization Name:LIFE CHANGE RX LLC
Other - Org Name:LIFE CHANGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:EL SHEIKH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:414-335-4617
Mailing Address - Street 1:7115 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2051
Mailing Address - Country:US
Mailing Address - Phone:414-600-2000
Mailing Address - Fax:414-600-0414
Practice Address - Street 1:1844 S 15TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3225
Practice Address - Country:US
Practice Address - Phone:414-335-4617
Practice Address - Fax:414-751-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071374Medicaid