Provider Demographics
NPI:1669958427
Name:LIVE WELL RX LLC
Entity type:Organization
Organization Name:LIVE WELL RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:734-927-2878
Mailing Address - Street 1:7651 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3270 GREENFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1161
Practice Address - Country:US
Practice Address - Phone:248-284-6969
Practice Address - Fax:248-284-6963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010114153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315094600OtherMICHIGAN PHARMACY CS LICENSE
MI5301011415OtherMICHIGAN PHARMACY LICENSE