Provider Demographics
NPI:1013322213
Name:HEALTH SHOPPE LLC
Entity Type:Organization
Organization Name:HEALTH SHOPPE LLC
Other - Org Name:LIFE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHONARA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:732-485-3078
Mailing Address - Street 1:1260 W COVELL RD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3555
Mailing Address - Country:US
Mailing Address - Phone:405-562-4242
Mailing Address - Fax:405-562-4535
Practice Address - Street 1:1260 W COVELL RD
Practice Address - Street 2:SUITE 124
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3555
Practice Address - Country:US
Practice Address - Phone:405-562-4242
Practice Address - Fax:405-562-4535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK1-67903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146599OtherPK
OK200559050Medicaid