Provider Demographics
NPI:1346597192
Name:LIVING WELL PHARMACY INC
Entity type:Organization
Organization Name:LIVING WELL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANE-LIPARI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-477-5483
Mailing Address - Street 1:3555 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6764
Mailing Address - Country:US
Mailing Address - Phone:718-477-5483
Mailing Address - Fax:718-477-5480
Practice Address - Street 1:3555 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6764
Practice Address - Country:US
Practice Address - Phone:718-477-5483
Practice Address - Fax:718-477-5480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-11
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0313113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03749213Medicaid
2136438OtherPK
NY03749213Medicaid