Provider Demographics
NPI:1104300862
Name:LIFESMART PHARMACY LLC
Entity type:Organization
Organization Name:LIFESMART PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-478-7823
Mailing Address - Street 1:2176 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2405
Mailing Address - Country:US
Mailing Address - Phone:313-768-5096
Mailing Address - Fax:313-768-5098
Practice Address - Street 1:2176 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2405
Practice Address - Country:US
Practice Address - Phone:313-768-5858
Practice Address - Fax:313-768-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy