Healthcare Provider Details

I. General information

NPI: 1760428684
Provider Name (Legal Business Name): LIFE TREE PHARMACY SERVICES INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BLUE HERON DR
COLLEGEVILLE PA
19426-2057
US

IV. Provider business mailing address

5 BLUE HERON DR
COLLEGEVILLE PA
19426-2057
US

V. Phone/Fax

Practice location:
  • Phone: 610-489-6640
  • Fax: 610-489-6645
Mailing address:
  • Phone: 610-489-6640
  • Fax: 610-489-6645

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 TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPP481454
License Number StatePA

VIII. Authorized Official

Name: MARK TAGLIANETTI
Title or Position: PRESIDENT
Credential:
Phone: 610-489-6640