Healthcare Provider Details

I. General information

NPI: 1992899306
Provider Name (Legal Business Name): EXTENDED LIVING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 W MARION AVE
FORSYTH IL
62535-1064
US

IV. Provider business mailing address

338 W MARION AVE
FORSYTH IL
62535-1064
US

V. Phone/Fax

Practice location:
  • Phone: 217-875-7147
  • Fax: 217-875-7081
Mailing address:
  • Phone: 217-875-7147
  • Fax: 217-875-7081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number054016055
License Number StateIL

VIII. Authorized Official

Name: JEFFREY AUBRY
Title or Position: MANAGER
Credential: RPH
Phone: 217-855-8378