Healthcare Provider Details

I. General information

NPI: 1285918086
Provider Name (Legal Business Name): LIVEWELL, INC. DBA CANNON PHARMACY COMPOUNDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 JACKSON PARK RD
KANNAPOLIS NC
28083-3657
US

IV. Provider business mailing address

563 JACKSON PARK RD
KANNAPOLIS NC
28083-3657
US

V. Phone/Fax

Practice location:
  • Phone: 704-932-5050
  • Fax: 704-933-7758
Mailing address:
  • Phone: 704-932-5050
  • Fax: 704-933-7758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number11070
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MATT MILLER
Title or Position: CO-OWNER
Credential: PHARMD
Phone: 704-658-9870