=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396015103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEWAY PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2012
-----------------------------------------------------
Last Update Date | 01/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1822 TOWER DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-4938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-323-5483
-----------------------------------------------------
Fax | 318-323-5485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1822 TOWER DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-4938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-323-5483
-----------------------------------------------------
Fax | 318-323-5485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST IN CHARGE
-----------------------------------------------------
Name | ERICA SULLIVAN DITTA
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 318-355-3202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 017373
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------