=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043350556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVEWELL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 01/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2334 SOUTH BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-523-8608
-----------------------------------------------------
Fax | 704-523-8619
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2334 SOUTH BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-523-8608
-----------------------------------------------------
Fax | 704-523-8619
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT PIC
-----------------------------------------------------
Name | BRIAN FREEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-933-6337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 10527
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------