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General NPI Number Information
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NPI Number | 1649706714
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Entity Type | Organization
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Legal Business Name | LIFE TREE PHARMACY LLC
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Dates
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Enumeration Date | 05/10/2017
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Last Update Date | 05/10/2017
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Provider Practice Location Address
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Address Line | 8329-5 W APPLETON AVE
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City | MILWAUKEE
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State | WI
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Zip | 53218
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Country | US
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Telephone | 414-698-5044
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Fax |
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Provider Business Mailing Address
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Address Line | 5450 W GREEN TREE RD
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City | MILWAUKEE
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State | WI
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Zip | 53223-5289
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHJARMACIST-IN-CHARGE
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Name | BENJAMIN ENERIAKPOZI EZEKIEL
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Credential |
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Telephone | 414-698-5044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 9459-42
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License Number State | WI
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