Provider Demographics
NPI:1558468488
Name:LIVEWELL INC
Entity Type:Organization
Organization Name:LIVEWELL INC
Other - Org Name:CANNON PHARMACY MORROCROFT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST MANAGER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DINAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:704-367-7440
Mailing Address - Street 1:4501 CAMERON VALLEY PKWY STE 125
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4299
Mailing Address - Country:US
Mailing Address - Phone:704-367-7440
Mailing Address - Fax:704-365-2345
Practice Address - Street 1:4501 CAMERON VALLEY PKWY STE 125
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4299
Practice Address - Country:US
Practice Address - Phone:704-367-7440
Practice Address - Fax:704-365-2345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC78833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0609491Medicaid
3427196OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5277830001Medicare NSC