=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659572097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFECHEK SWEENY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 04/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N MAIN ST
-----------------------------------------------------
City | SWEENY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-548-0212
-----------------------------------------------------
Fax | 979-548-0116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 N. MAIN ST
-----------------------------------------------------
City | SWEENY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-548-0212
-----------------------------------------------------
Fax | 979-548-0116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COMPLIANCE COORDINATOR
-----------------------------------------------------
Name | COLIN GINGRICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-232-3940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 25569
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------