Provider Demographics
NPI:1821460403
Name:LIFECARE PHARMACY
Entity Type:Organization
Organization Name:LIFECARE PHARMACY
Other - Org Name:LIFECARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALTAMASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-619-9786
Mailing Address - Street 1:276 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-3767
Mailing Address - Country:US
Mailing Address - Phone:630-543-1000
Mailing Address - Fax:630-543-1002
Practice Address - Street 1:276 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-3767
Practice Address - Country:US
Practice Address - Phone:630-543-1000
Practice Address - Fax:630-543-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054.0195343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154865OtherPK
2154865OtherPK