Provider Demographics
NPI:1477640548
Name:LIFE WELLNESS PHARMACY, INC.
Entity Type:Organization
Organization Name:LIFE WELLNESS PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LENZNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-210-9434
Mailing Address - Street 1:1932 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-6581
Mailing Address - Country:US
Mailing Address - Phone:800-210-9434
Mailing Address - Fax:800-210-6942
Practice Address - Street 1:1932 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-6581
Practice Address - Country:US
Practice Address - Phone:800-210-9434
Practice Address - Fax:800-210-6942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45971333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4571480001Medicare NSC