MEDICARE: LIFESMART PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1104300862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESMART PHARMACY LLC

Provider Business Mailing Address
First Line	:	2176 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2405
Country	:	US
Telephone Number	:	313-768-5096
Fax Number	:	313-768-5098

Provider Business Practice Location Address
First Line	:	2176 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2405
Country	:	US
Telephone Number	:	313-768-5858
Fax Number	:	313-768-5868

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	ADHAM MALLAH
Credential	:
Telephone Number	:	313-478-7823

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	09/08/2023

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Directions to “LIFESMART PHARMACY LLC ” Practice Location

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