Provider Demographics
NPI:1689171852
Name:LIFE INFUSION PHARMACY CORP
Entity Type:Organization
Organization Name:LIFE INFUSION PHARMACY CORP
Other - Org Name:LIFE INFUSIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-575-2231
Mailing Address - Street 1:4301 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-1429
Mailing Address - Country:US
Mailing Address - Phone:718-438-1421
Mailing Address - Fax:
Practice Address - Street 1:672 UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2210
Practice Address - Country:US
Practice Address - Phone:718-981-9819
Practice Address - Fax:718-981-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0360333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176518OtherPK