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General NPI Number Information
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NPI Number | 1699334532
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Entity Type | Organization
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Legal Business Name | LONG LIFE PHARMACY LLC
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Dates
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Enumeration Date | 06/12/2019
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Last Update Date | 09/01/2023
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Provider Practice Location Address
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Address Line | 1672 S 9TH ST UNIT D
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City | MILWAUKEE
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State | WI
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Zip | 53204-3426
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Country | US
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Telephone | 414-326-0888
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Fax |
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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 | 414-375-6112
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MOATH M SARSOUR
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Credential | PH-D
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Telephone | 414-375-6112
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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 |
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License Number State |
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