Provider Demographics
NPI:1720495401
Name:GOOD LIFE APOTHECARY, INC
Entity Type:Organization
Organization Name:GOOD LIFE APOTHECARY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-552-8765
Mailing Address - Street 1:3212 PENNSYLVANIA AVE # 8
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-4537
Mailing Address - Country:US
Mailing Address - Phone:304-345-8600
Mailing Address - Fax:304-345-8602
Practice Address - Street 1:3212 PENN AVE # 8
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4537
Practice Address - Country:US
Practice Address - Phone:304-345-8600
Practice Address - Fax:304-345-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910006007Medicaid