Provider Demographics
NPI:1750788816
Name:LIFECARE PHARMACY, LLC
Entity type:Organization
Organization Name:LIFECARE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLETUS
Authorized Official - Middle Name:
Authorized Official - Last Name:AMADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-697-2105
Mailing Address - Street 1:3050 E DESERT INN RD
Mailing Address - Street 2:STE 124
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3870
Mailing Address - Country:US
Mailing Address - Phone:702-697-2105
Mailing Address - Fax:702-697-2107
Practice Address - Street 1:3050 E DESERT INN RD
Practice Address - Street 2:STE 124
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3870
Practice Address - Country:US
Practice Address - Phone:702-697-2105
Practice Address - Fax:702-697-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336M0003X
NVPH017983336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149104OtherPK