Provider Demographics
NPI:1467878389
Name:WELL LIFE COMPOUNDING LLC
Entity Type:Organization
Organization Name:WELL LIFE COMPOUNDING LLC
Other - Org Name:WELL LIFE LIBERTY LAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-755-3333
Mailing Address - Street 1:6603 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8522
Mailing Address - Country:US
Mailing Address - Phone:208-267-4004
Mailing Address - Fax:208-267-7405
Practice Address - Street 1:23801 E APPLEWAY AVE
Practice Address - Street 2:STE 260
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9687
Practice Address - Country:US
Practice Address - Phone:509-255-7611
Practice Address - Fax:509-755-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHAR.CF.00059100333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144734OtherPK