Provider Demographics
NPI:1609352566
Name:TRIPHARMA INC
Entity Type:Organization
Organization Name:TRIPHARMA INC
Other - Org Name:LIVE WELL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LYKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-770-0111
Mailing Address - Street 1:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-1095
Mailing Address - Country:US
Mailing Address - Phone:479-271-9355
Mailing Address - Fax:479-271-9357
Practice Address - Street 1:3500 SW REGIONAL AIRPORT BLVD STE 2
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-271-9355
Practice Address - Fax:479-770-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR223890407Medicaid