MEDICARE: NULIFE PHARMACY, INC

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	:	1619448248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NULIFE PHARMACY, INC

Provider Business Mailing Address
First Line	:	14150 TRINITY BLVD STE 750
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-2597
Country	:	US
Telephone Number	:	817-769-7941
Fax Number	:	817-769-8332

Provider Business Practice Location Address
First Line	:	14150 TRINITY BLVD STE 750
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-2597
Country	:	US
Telephone Number	:	817-769-7941
Fax Number	:	817-769-8332

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MR. JAGADEESH JANJANAM
Credential	:
Telephone Number	:	817-769-7941

Provider Enumeration Date	:	12/07/2018
Last Update Date	:	10/31/2019

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