Provider Demographics
NPI:1609295211
Name:LIFE TREE PHARMACY SERVICES INCORPORATED
Entity Type:Organization
Organization Name:LIFE TREE PHARMACY SERVICES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:TAGLIANETTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-450-6987
Mailing Address - Street 1:5 BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2057
Mailing Address - Country:US
Mailing Address - Phone:610-489-6640
Mailing Address - Fax:610-489-6645
Practice Address - Street 1:800 CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:SHARON HILL
Practice Address - State:PA
Practice Address - Zip Code:19079-1400
Practice Address - Country:US
Practice Address - Phone:855-345-3275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482442333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482442OtherPA STATE PHARMACY LICENSE
PA1013015200004Medicaid