=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285557926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEFILL III, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2026
-----------------------------------------------------
Last Update Date | 07/31/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3597 E MONARCH SKY LN. SUITE 240 OFC 215
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-247-3184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 BROADWAY RM 1910
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-2874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP, CLOUD AND SPECIALTY PHARMACY
-----------------------------------------------------
Name | MICHAEL NAMETH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-201-9585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------