Provider Demographics
NPI:1659612737
Name:LIFECARE SPECIALTY
Entity Type:Organization
Organization Name:LIFECARE SPECIALTY
Other - Org Name:LIFECARE SPECIALTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:L
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-676-0078
Mailing Address - Street 1:1646 SUNRISE PLACE STE B
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084
Mailing Address - Country:US
Mailing Address - Phone:801-676-0078
Mailing Address - Fax:801-676-0079
Practice Address - Street 1:1646 SUNRISE PLACE STE B
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084
Practice Address - Country:US
Practice Address - Phone:801-676-0078
Practice Address - Fax:801-676-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336H0001X, 3336M0002X
UT8473547-17043336L0003X
UT847354717043336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4612481OtherNCPDP PROVIDER IDENTIFICATION NUMBER