Provider Demographics
NPI:1659441624
Name:LIFE SPECIALTY PHARMACY MEDICAL EQUIPMENT AND SUPPLIES INC.
Entity Type:Organization
Organization Name:LIFE SPECIALTY PHARMACY MEDICAL EQUIPMENT AND SUPPLIES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOTUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-522-5683
Mailing Address - Street 1:1507 PARK CENTER DRIVE
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5795
Mailing Address - Country:US
Mailing Address - Phone:407-522-5683
Mailing Address - Fax:407-522-5684
Practice Address - Street 1:1507 PARK CENTER DRIVE
Practice Address - Street 2:SUITE 1K
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5795
Practice Address - Country:US
Practice Address - Phone:407-405-0735
Practice Address - Fax:407-522-5684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 22346333600000X, 3336C0002X, 3336C0004X, 3336H0001X, 3336I0012X, 3336L0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1659441624OtherNPI
FL031807800Medicaid
FL031807800Medicaid