Provider Demographics
NPI:1891043592
Name:LUU DRUG STORES LLC
Entity Type:Organization
Organization Name:LUU DRUG STORES LLC
Other - Org Name:LIVE WELL PHARMACY @ RISING SUN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LUU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-761-6625
Mailing Address - Street 1:3811 SCHOOL LN
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-3113
Mailing Address - Country:US
Mailing Address - Phone:610-626-4549
Mailing Address - Fax:
Practice Address - Street 1:5805 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1125
Practice Address - Country:US
Practice Address - Phone:215-821-2883
Practice Address - Fax:215-821-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4822983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027532470001Medicaid
2136709OtherPK
2136709OtherPK