Provider Demographics
NPI:1952965576
Name:LIFE CHANGE RX 1 LLC
Entity type:Organization
Organization Name:LIFE CHANGE RX 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-600-2000
Mailing Address - Street 1:1844 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3225
Mailing Address - Country:US
Mailing Address - Phone:414-600-2000
Mailing Address - Fax:414-600-0414
Practice Address - Street 1:7115 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2051
Practice Address - Country:US
Practice Address - Phone:414-600-2000
Practice Address - Fax:414-600-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071374Medicaid