Organization
LIFETIME PHARMACY CORP
Active
Organization
LIFETIME PHARMACY CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RONALD VANDYKE (CEO)
(951) 656-7171
Entity
Organization
Contact information
Practice address
23080 ALESSANDRO BLVD, STE 212, MORENO VALLEY, CA 92553-9673
(951) 656-7171
(951) 656-6363
Mailing address
23080 ALESSANDRO BLVD, STE 212, MORENO VALLEY, CA 92553-9673
(951) 656-7171
(951) 656-6363
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2117475
PK
—
05
—
6691210001
—
CA
Enumeration date
10/04/2008
Last updated
03/10/2020
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