Healthcare Provider Details

I. General information

NPI: 1891561593
Provider Name (Legal Business Name): SENIOR LIFE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5002 ELK RIVER RD S
ELKVIEW WV
25071-9619
US

IV. Provider business mailing address

100 S MADISON ST
THOMASVILLE GA
31792-5473
US

V. Phone/Fax

Practice location:
  • Phone: 304-407-6437
  • Fax:
Mailing address:
  • Phone: 912-223-6326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KASEY KNIGHT
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 912-223-6326