MEDICARE: LIVE WELL 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	PP482041	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2125849	OTHER		PK

General Provider Information

NPI Number	:	1306159579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE WELL PHARMACY LLC

Provider Business Mailing Address
First Line	:	2453 GRANT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1004
Country	:	US
Telephone Number	:	215-437-9255
Fax Number	:	215-941-7910

Provider Business Practice Location Address
First Line	:	2453 GRANT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1004
Country	:	US
Telephone Number	:	215-437-9255
Fax Number	:	215-941-7910

Authorized Official
Title or Position	:	OWNER/PIC/PHCY MGR
Name	:	KAREN LUU
Credential	:	RPH
Telephone Number	:	215-437-9255

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	05/06/2014

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Directions to “LIVE WELL PHARMACY LLC ” Practice Location

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