Healthcare Provider Details

I. General information

NPI: 1114901600
Provider Name (Legal Business Name): LISA RIBBLE I BS, PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E LASALLE AVE
SOUTH BEND IN
46617-2814
US

IV. Provider business mailing address

16045 BAYWOOD LN
GRANGER IN
46530-9179
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-7688
  • Fax: 574-236-5005
Mailing address:
  • Phone: 574-273-4974
  • Fax: 574-236-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26019522A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: