Provider Demographics
NPI:1043569338
Name:LIVE WELL PHARMACY INC
Entity type:Organization
Organization Name:LIVE WELL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NOORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERAM
Authorized Official - Suffix:
Authorized Official - Credentials:BSC PHARMACY
Authorized Official - Phone:248-381-4000
Mailing Address - Street 1:23411 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1404
Mailing Address - Country:US
Mailing Address - Phone:248-381-4000
Mailing Address - Fax:248-381-4046
Practice Address - Street 1:23411 JOHN R RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1404
Practice Address - Country:US
Practice Address - Phone:248-381-4000
Practice Address - Fax:248-381-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-03
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010100263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138523OtherPK
MI1043569338Medicaid