Provider Demographics
NPI:1891561593
Name:SENIOR LIFE PHARMACY LLC
Entity Type:Organization
Organization Name:SENIOR LIFE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-223-6326
Mailing Address - Street 1:100 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5473
Mailing Address - Country:US
Mailing Address - Phone:912-223-6326
Mailing Address - Fax:
Practice Address - Street 1:5002 ELK RIVER RD S
Practice Address - Street 2:
Practice Address - City:ELKVIEW
Practice Address - State:WV
Practice Address - Zip Code:25071-9619
Practice Address - Country:US
Practice Address - Phone:304-407-6437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy