Healthcare Provider Details

I. General information

NPI: 1295148625
Provider Name (Legal Business Name): LIFESPAN PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SUMMIT AVE
PROVIDENCE RI
02906-2853
US

IV. Provider business mailing address

164 SUMMIT AVE
PROVIDENCE RI
02906-2853
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-5500
  • Fax: 401-793-5601
Mailing address:
  • Phone: 401-793-5500
  • Fax: 401-793-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHA00565
License Number StateRI

VIII. Authorized Official

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