Provider Demographics
NPI:1629961297
Name:PURE LIFE PHARMACY LLC
Entity type:Organization
Organization Name:PURE LIFE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:313-467-0264
Mailing Address - Street 1:820 S PEMBERTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1443
Mailing Address - Country:US
Mailing Address - Phone:313-467-0264
Mailing Address - Fax:
Practice Address - Street 1:1373 DIX HWY
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1346
Practice Address - Country:US
Practice Address - Phone:313-467-0264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy