Provider Demographics
NPI:1437470499
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:563-659-8910
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 1:1021 11TH ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1209
Practice Address - Country:US
Practice Address - Phone:563-659-8910
Practice Address - Fax:563-659-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IA12283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1437470499Medicaid
IA0419267Medicaid
2125508OtherPK