Organization
LIFESOURCE PLUS INC
Active
Other names
Lifesource Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
CRYSTAL WONG (PRESIDENT)
(718) 803-8393
Entity
Organization
Contact information
Practice address
8514 QUEENS BLVD, ELMHURST, NY 11373-4249
(718) 803-8393
Mailing address
8514 QUEENS BLVD, ELMHURST, NY 11373-4249
(718) 803-8393
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
031093
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5804314
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
01/30/2012
Last updated
05/04/2012
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