Provider Demographics
NPI:1194144691
Name:LIFEMED ILLINOIS, LLC
Entity type:Organization
Organization Name:LIFEMED ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:954-385-4998
Mailing Address - Street 1:15491 SW 12TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1991
Mailing Address - Country:US
Mailing Address - Phone:954-385-4998
Mailing Address - Fax:954-385-4942
Practice Address - Street 1:881 IL ROUTE 83
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-1219
Practice Address - Country:US
Practice Address - Phone:888-806-3379
Practice Address - Fax:954-385-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy