Provider Demographics
NPI:1760428684
Name:LIFE TREE PHARMACY SERVICES INCORPORATED
Entity Type:Organization
Organization Name:LIFE TREE PHARMACY SERVICES INCORPORATED
Other - Org Name:LIFE TREE PHARMACY SERVICES INCORPORATED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TAGLIANETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-489-6640
Mailing Address - Street 1:5 BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2057
Mailing Address - Country:US
Mailing Address - Phone:610-489-6640
Mailing Address - Fax:610-489-6645
Practice Address - Street 1:5 BLUE HERON DR
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-2057
Practice Address - Country:US
Practice Address - Phone:610-489-6640
Practice Address - Fax:610-489-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X, 3336I0012X
PAPP4814543336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013015200001Medicaid
2085292OtherPK
PA1013015200001Medicaid