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General NPI Number Information
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NPI Number | 1194144691
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Entity Type | Organization
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Legal Business Name | LIFEMED ILLINOIS, LLC
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Dates
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Enumeration Date | 04/11/2014
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Last Update Date | 04/11/2014
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Provider Practice Location Address
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Address Line | 881 IL ROUTE 83
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City | BENSENVILLE
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State | IL
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Zip | 60106-1219
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Country | US
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Telephone | 888-806-3379
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Fax | 954-385-4942
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Provider Business Mailing Address
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Address Line | 15491 SW 12TH ST SUITE 400
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City | SUNRISE
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State | FL
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Zip | 33326-1991
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Country | US
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Telephone | 954-385-4998
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Fax | 954-385-4942
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Authorized Official
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Title or Position | MANAGER
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Name | DR. DAVID MAYA
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Credential | PHARM. D.
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Telephone | 954-385-4998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State | IL
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