Provider Demographics
NPI:1841613981
Name:LIFEFOUNTAIN PHARMACY CORP
Entity Type:Organization
Organization Name:LIFEFOUNTAIN PHARMACY CORP
Other - Org Name:CHOICE SPECIALTY PHARMACY 11
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HARISH
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-309-4800
Mailing Address - Street 1:8850 SIX PINES DR STE 150
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2688
Mailing Address - Country:US
Mailing Address - Phone:346-309-4800
Mailing Address - Fax:832-616-3489
Practice Address - Street 1:8850 SIX PINES DR STE 150
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2688
Practice Address - Country:US
Practice Address - Phone:346-309-4800
Practice Address - Fax:832-616-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336H0001X, 3336S0011X
TX289583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144018OtherPK