Provider Demographics
NPI:1558512848
Name:LIFETIME PHARMACY CORP
Entity Type:Organization
Organization Name:LIFETIME PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-656-7171
Mailing Address - Street 1:23080 ALESSANDRO BLVD
Mailing Address - Street 2:STE 212
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9673
Mailing Address - Country:US
Mailing Address - Phone:951-656-7171
Mailing Address - Fax:951-656-6363
Practice Address - Street 1:23080 ALESSANDRO BLVD
Practice Address - Street 2:STE 212
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9673
Practice Address - Country:US
Practice Address - Phone:951-656-7171
Practice Address - Fax:951-656-6363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-04
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6691210001Medicaid
2117475OtherPK
2117475OtherPK