=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275822421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD LIFE PHARMACY AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2011
-----------------------------------------------------
Last Update Date | 12/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 953 MAIN ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07503-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-782-6868
-----------------------------------------------------
Fax | 973-782-6870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7900 KENNEDY BLVD
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-654-1862
-----------------------------------------------------
Fax | 201-751-4191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIRVAT KADDOUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-782-6868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00714700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------