Healthcare Provider Details

I. General information

NPI: 1255934154
Provider Name (Legal Business Name): LISA LEVANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2020
Last Update Date: 11/21/2020
Certification Date: 11/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 E ERIE ST
MISSOURI VALLEY IA
51555-1619
US

IV. Provider business mailing address

312 E ERIE ST APT 3
MISSOURI VALLEY IA
51555-1660
US

V. Phone/Fax

Practice location:
  • Phone: 712-642-2747
  • Fax:
Mailing address:
  • Phone: 402-741-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16453
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: