Provider Demographics
NPI:1689925299
Name:LIVEWELL INC
Entity Type:Organization
Organization Name:LIVEWELL INC
Other - Org Name:CANNON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:VELTRI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:704-933-6337
Mailing Address - Street 1:1706 S CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6104
Mailing Address - Country:US
Mailing Address - Phone:704-933-6337
Mailing Address - Fax:704-933-6374
Practice Address - Street 1:1706 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6104
Practice Address - Country:US
Practice Address - Phone:704-933-6337
Practice Address - Fax:704-933-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC088811835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0135919Medicaid