Healthcare Provider Details

I. General information

NPI: 1508391343
Provider Name (Legal Business Name): LIFELINE PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E MAIN ST STE 4
EAST DUNDEE IL
60118-1523
US

IV. Provider business mailing address

455 E MAIN ST STE 4
EAST DUNDEE IL
60118-1523
US

V. Phone/Fax

Practice location:
  • Phone: 847-450-0900
  • Fax: 847-450-0920
Mailing address:
  • Phone: 847-450-0900
  • Fax: 847-450-0920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number054020245
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHITAL MANEK
Title or Position: OWNER
Credential:
Phone: 630-777-7800