Provider Demographics
NPI:1497355002
Name:LONG LIFE PHARMACY 2 LLC
Entity Type:Organization
Organization Name:LONG LIFE PHARMACY 2 LLC
Other - Org Name:LONG LIFE PHARMACY 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOATH
Authorized Official - Middle Name:
Authorized Official - Last Name:SARSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:414-377-7717
Mailing Address - Street 1:1255 E HICKORY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-7316
Mailing Address - Country:US
Mailing Address - Phone:414-377-7717
Mailing Address - Fax:414-377-7719
Practice Address - Street 1:932 S 60TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3369
Practice Address - Country:US
Practice Address - Phone:414-375-6112
Practice Address - Fax:414-375-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-01
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy