Provider Demographics
NPI:1154965317
Name:LIVEWELL PHARMACY INC
Entity type:Organization
Organization Name:LIVEWELL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHAUDHARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-843-8562
Mailing Address - Street 1:1432 E GUN HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3061
Mailing Address - Country:US
Mailing Address - Phone:347-843-8562
Mailing Address - Fax:347-843-8565
Practice Address - Street 1:1432 E GUN HILL RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3061
Practice Address - Country:US
Practice Address - Phone:347-843-8562
Practice Address - Fax:347-843-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06077178Medicaid