Healthcare Provider Details

I. General information

NPI: 1467530873
Provider Name (Legal Business Name): LIFE EXTENSION PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5990 N FEDERAL HWY
FORT LAUDERDALE FL
33308-2633
US

IV. Provider business mailing address

3600 W COMMERCIAL BLVD
FORT LAUDERDALE FL
33309-3338
US

V. Phone/Fax

Practice location:
  • Phone: 877-877-9700
  • Fax: 877-877-9708
Mailing address:
  • Phone: 954-202-7729
  • Fax: 954-202-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH22301
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MELANIE KAMBURIAN
Title or Position: PARALEGAL
Credential: PHARMACIST
Phone: 954-202-7729