Provider Demographics
NPI:1649706714
Name:LIFE TREE PHARMACY LLC
Entity type:Organization
Organization Name:LIFE TREE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHJARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ENERIAKPOZI
Authorized Official - Last Name:EZEKIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-698-5044
Mailing Address - Street 1:5450 W GREEN TREE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-5289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8329-5 W APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:414-698-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9459-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy