Provider Demographics
NPI:1720548118
Name:LIFE SPECIALTY PHARMACY, INC.
Entity Type:Organization
Organization Name:LIFE SPECIALTY PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAJI
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-681-5959
Mailing Address - Street 1:18770 LBJ FWY STE 200
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:949 W. KEARNEY ST.
Practice Address - Street 2:SUITE 107
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149
Practice Address - Country:US
Practice Address - Phone:972-681-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-21
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150116Medicaid