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General NPI Number Information
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NPI Number | 1497355002
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Entity Type | Organization
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Legal Business Name | LONG LIFE PHARMACY 2 LLC
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Dates
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Enumeration Date | 11/01/2020
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Last Update Date | 04/04/2024
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Provider Practice Location Address
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Address Line | 932 S 60TH ST
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City | WEST ALLIS
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State | WI
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Zip | 53214-3369
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Country | US
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Telephone | 414-375-6112
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Fax | 414-375-6113
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Provider Business Mailing Address
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Address Line | 1255 E HICKORY CREEK CT
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City | OAK CREEK
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State | WI
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Zip | 53154-7316
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Country | US
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Telephone | 414-377-7717
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Fax | 414-377-7719
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Authorized Official
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Title or Position | OWNER AND PHARMACIST
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Name | DR. MOATH SARSOUR
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Credential | PHARMD
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Telephone | 414-377-7717
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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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