Provider Demographics
NPI:1992262869
Name:GOODLIFE PHARMACY
Entity type:Organization
Organization Name:GOODLIFE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHACKO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PUTHENTHARAYIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-280-5005
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLIVET
Mailing Address - State:MI
Mailing Address - Zip Code:49076-9403
Mailing Address - Country:US
Mailing Address - Phone:269-280-5005
Mailing Address - Fax:
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OLIVET
Practice Address - State:MI
Practice Address - Zip Code:49076-9403
Practice Address - Country:US
Practice Address - Phone:718-938-0263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy