Healthcare Provider Details

I. General information

NPI: 1962123778
Provider Name (Legal Business Name): LIFE PHARMA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 NW 22ND AVE
MIAMI FL
33125
US

IV. Provider business mailing address

1109 NW 22ND AVE
MIAMI FL
33125
US

V. Phone/Fax

Practice location:
  • Phone: 305-646-1111
  • Fax: 786-703-1242
Mailing address:
  • Phone: 305-646-1111
  • Fax: 786-703-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JORGE L HERNANDEZ LARA
Title or Position: PRESIDENT
Credential:
Phone: 305-646-1111