Healthcare Provider Details

I. General information

NPI: 1174321764
Provider Name (Legal Business Name): LIFESPAN PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 W RIVER ST STE 2B
PROVIDENCE RI
02904-2615
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-9909
  • Fax: 401-444-4095
Mailing address:
  • Phone: 401-444-2672
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PETER K MARKELL
Title or Position: EVP & CFO
Credential:
Phone: 401-444-7914