Provider Demographics
NPI:1578736344
Name:LIVE WELL DRUGSTORE LLC
Entity Type:Organization
Organization Name:LIVE WELL DRUGSTORE LLC
Other - Org Name:BIOWORX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY MANG
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-531-3030
Mailing Address - Street 1:3516 ENTERPRISE WAY
Mailing Address - Street 2:STE 7 AND 8
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-9319
Mailing Address - Country:US
Mailing Address - Phone:904-531-3030
Mailing Address - Fax:904-531-3060
Practice Address - Street 1:3516 ENTERPRISE WAY
Practice Address - Street 2:STE 7 AND 8
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-9319
Practice Address - Country:US
Practice Address - Phone:904-531-3030
Practice Address - Fax:904-531-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH232933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2011342OtherPK