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General NPI Number Information
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NPI Number | 1215397385
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Entity Type | Organization
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Legal Business Name | LIFEWAY HOLDINGS LLC
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Dates
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Enumeration Date | 03/02/2016
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Last Update Date | 08/11/2022
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Provider Practice Location Address
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Address Line | 700 MERRITT BLVD SUITE 1A
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City | DUNDALK
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State | MD
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Zip | 21222
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Country | US
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Telephone | 443-530-3731
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Fax | 443-530-3859
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Provider Business Mailing Address
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Address Line | 700 MERRITT BLVD SUITE 1A
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City | DUNDALK
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State | MD
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Zip | 21222
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Country | US
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Telephone | 443-530-3731
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Fax | 443-530-3859
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Authorized Official
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Title or Position | DIRECTOR/PHARMACIST I/C
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Name | MR. EDMOND ISAAC NGAZAL
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Credential |
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Telephone | 443-531-3107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | P07159
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License Number State | MD
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