Healthcare Provider Details

I. General information

NPI: 1831998467
Provider Name (Legal Business Name): LIFETIME PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W EDISON RD STE A
MISHAWAKA IN
46545-8301
US

IV. Provider business mailing address

19120 OAKMONT SOUTH DR
SOUTH BEND IN
46637-3529
US

V. Phone/Fax

Practice location:
  • Phone: 574-318-4195
  • Fax: 574-318-4936
Mailing address:
  • Phone: 313-828-2794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: HASSAN FAKIH
Title or Position: OWNER/PIC
Credential: PHARMD
Phone: 574-318-4195