Healthcare Provider Details

I. General information

NPI: 1811148836
Provider Name (Legal Business Name): JESSIE ROSE LISH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W PRATT ST APARTMENT 1820
BALTIMORE MD
21201-1648
US

IV. Provider business mailing address

511 WEST PRATT STREET APARTMENT 1820
BALTIMORE MD
21201
US

V. Phone/Fax

Practice location:
  • Phone: 908-303-9089
  • Fax:
Mailing address:
  • Phone: 908-303-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number18764
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: