Provider Demographics
NPI:1205869674
Name:GOODLIFE RX LLC
Entity type:Organization
Organization Name:GOODLIFE RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THUY MIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-294-3219
Mailing Address - Street 1:25 N 14TH STREET
Mailing Address - Street 2:STE 110
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-6208
Mailing Address - Country:US
Mailing Address - Phone:408-294-3219
Mailing Address - Fax:408-294-3238
Practice Address - Street 1:25 N 14TH STREET
Practice Address - Street 2:STE 110
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6208
Practice Address - Country:US
Practice Address - Phone:408-294-3219
Practice Address - Fax:408-294-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY554773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1205869674OtherMEDI-CAL PROVIDER NUMBER
CAPHY55477OtherBOARD OF PHARMACY PERMIT
CA05-21092OtherNCPDP NUMBER