Provider Demographics
NPI:1780904854
Name:LIFE RX INC
Entity type:Organization
Organization Name:LIFE RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-659-5041
Mailing Address - Street 1:SCOTT'S THRIFTY WHITE DRUG
Mailing Address - Street 2:629 6TH AVE
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742
Mailing Address - Country:US
Mailing Address - Phone:563-659-5042
Mailing Address - Fax:563-659-5044
Practice Address - Street 1:609 7TH AVE
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:IA
Practice Address - Zip Code:52742
Practice Address - Country:US
Practice Address - Phone:563-659-5042
Practice Address - Fax:563-659-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12123336L0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125507OtherPK
IA0001331Medicaid