Basic Information
| Provider Information | |||||||||
| NPI: | 1144792383 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFESPAN PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIFESPAN PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 CORLISS STREET | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444909 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2018 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | KIRSHNER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4014447914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.