Provider Demographics
NPI:1932573425
Name:LIFETREE PHARMACY, LLC
Entity Type:Organization
Organization Name:LIFETREE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHEPARDSON
Authorized Official - Middle Name:WILLCOX
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-595-4900
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:CABIN CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:25035-0280
Mailing Address - Country:US
Mailing Address - Phone:304-595-4900
Mailing Address - Fax:304-595-4652
Practice Address - Street 1:15063 MACCORKLE AVE., SE
Practice Address - Street 2:
Practice Address - City:CABIN CREEK
Practice Address - State:WV
Practice Address - Zip Code:25035-8047
Practice Address - Country:US
Practice Address - Phone:304-595-4900
Practice Address - Fax:304-595-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552501333600000X
3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1932573425Medicaid
2157687OtherPK