Provider Demographics
NPI:1467530873
Name:LIFE EXTENSION PHARMACY INC
Entity Type:Organization
Organization Name:LIFE EXTENSION PHARMACY INC
Other - Org Name:LIFE EXTENSION PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARALEGAL
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMBURIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:954-202-7729
Mailing Address - Street 1:3600 W COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3338
Mailing Address - Country:US
Mailing Address - Phone:954-202-7729
Mailing Address - Fax:954-202-7729
Practice Address - Street 1:5990 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2633
Practice Address - Country:US
Practice Address - Phone:877-877-9700
Practice Address - Fax:877-877-9708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336M0002X
FLPH223013336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2007736OtherPK