Provider Demographics
NPI:1760621155
Name:LIFEFIRST PHARMACY
Entity Type:Organization
Organization Name:LIFEFIRST PHARMACY
Other - Org Name:LIFEFIRST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBIAJULU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-646-5433
Mailing Address - Street 1:2407 W CHARLESTON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2138
Mailing Address - Country:US
Mailing Address - Phone:702-646-5433
Mailing Address - Fax:702-646-1696
Practice Address - Street 1:2407 W CHARLESTON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2138
Practice Address - Country:US
Practice Address - Phone:702-646-5433
Practice Address - Fax:702-646-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
NVPH02475333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1760621155Medicaid
2118837OtherPK
2118837OtherPK