Provider Demographics
NPI:1144255357
Name:LIFESTREAM PHARMACY INC
Entity type:Organization
Organization Name:LIFESTREAM PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MELEKOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:215-491-0999
Mailing Address - Street 1:847 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:WARRINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:18976-2906
Mailing Address - Country:US
Mailing Address - Phone:215-491-0999
Mailing Address - Fax:215-491-0977
Practice Address - Street 1:847 EASTON RD
Practice Address - Street 2:
Practice Address - City:WARRINGTON
Practice Address - State:PA
Practice Address - Zip Code:18976-2906
Practice Address - Country:US
Practice Address - Phone:215-491-0999
Practice Address - Fax:215-491-0977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 333600000X
PAPP4815433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015654020001Medicaid
2087685OtherPK
PA1015654020001Medicaid