Healthcare Provider Details

I. General information

NPI: 1659441624
Provider Name (Legal Business Name): LIFE SPECIALTY PHARMACY MEDICAL EQUIPMENT AND SUPPLIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 PARK CENTER DRIVE SUITE 1K
ORLANDO FL
32835-5795
US

IV. Provider business mailing address

1507 PARK CENTER DRIVE SUITE 1K
ORLANDO FL
32835-5795
US

V. Phone/Fax

Practice location:
  • Phone: 407-405-0735
  • Fax: 407-522-5684
Mailing address:
  • Phone: 407-522-5683
  • Fax: 407-522-5684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH 22346
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPH 22346
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH 22346
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPH 22346
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberPH 22346
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH 22346
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberPH 22346
License Number StateFL

VIII. Authorized Official

Name: MICHAEL AYOTUNDE
Title or Position: PRESIDENT OWNER
Credential:
Phone: 407-522-5683