Provider Demographics
NPI:1619604154
Name:HEALTHY LIFE PHARMACY LLC
Entity Type:Organization
Organization Name:HEALTHY LIFE PHARMACY LLC
Other - Org Name:HEALTHY LIFE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR/SOLE MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-734-8588
Mailing Address - Street 1:1004 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-8720
Mailing Address - Country:US
Mailing Address - Phone:314-803-2352
Mailing Address - Fax:
Practice Address - Street 1:1013 CEDAR ST
Practice Address - Street 2:STE B
Practice Address - City:BISMARCK
Practice Address - State:MO
Practice Address - Zip Code:63624
Practice Address - Country:US
Practice Address - Phone:573-734-8588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013372952OtherINDIVIDUAL PROVIDER NPI FOR LAURA HAYNES