Provider Demographics
NPI:1992802839
Name:LIVEWELL INC
Entity type:Organization
Organization Name:LIVEWELL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-933-6337
Mailing Address - Street 1:1706 S CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6104
Mailing Address - Country:US
Mailing Address - Phone:704-933-6337
Mailing Address - Fax:704-933-6374
Practice Address - Street 1:1706 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6104
Practice Address - Country:US
Practice Address - Phone:704-933-6337
Practice Address - Fax:704-933-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC088813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0135919Medicaid
2067567OtherPK
5277830002Medicare NSC