Provider Demographics
NPI:1811536683
Name:ACTIVE LIFESTYLE PHARMACY LLC
Entity type:Organization
Organization Name:ACTIVE LIFESTYLE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:M
Authorized Official - Last Name:LICKTEIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-760-3839
Mailing Address - Street 1:7800 FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2955
Mailing Address - Country:US
Mailing Address - Phone:913-730-8731
Mailing Address - Fax:844-842-0014
Practice Address - Street 1:7800 FOSTER ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-2955
Practice Address - Country:US
Practice Address - Phone:913-730-8731
Practice Address - Fax:844-842-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy