Healthcare Provider Details

I. General information

NPI: 1871598193
Provider Name (Legal Business Name): LISA ANN HETTICH PHARMD, CGP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 S COUNTY ROAD 1000 E
CLOVERDALE IN
46120-8528
US

IV. Provider business mailing address

6651 S COUNTY ROAD 1000 E
CLOVERDALE IN
46120-8528
US

V. Phone/Fax

Practice location:
  • Phone: 765-720-2775
  • Fax: 765-526-8066
Mailing address:
  • Phone: 765-720-2775
  • Fax: 765-526-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number26019317A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: