Provider Demographics
NPI:1992899306
Name:EXTENDED LIVING PHARMACY LLC
Entity type:Organization
Organization Name:EXTENDED LIVING PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUBRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-855-8378
Mailing Address - Street 1:338 W MARION AVE
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-1064
Mailing Address - Country:US
Mailing Address - Phone:217-875-7147
Mailing Address - Fax:217-875-7081
Practice Address - Street 1:338 W MARION AVE
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-1064
Practice Address - Country:US
Practice Address - Phone:217-875-7147
Practice Address - Fax:217-875-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
IL0540160553336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023265OtherPK