Healthcare Provider Details

I. General information

NPI: 1689981425
Provider Name (Legal Business Name): LISA R DYSARD PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA R WHITTEMORE

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 E WILCOX AVE
WHITE CLOUD MI
49349-8794
US

IV. Provider business mailing address

19592 PARK RD
BIG RAPIDS MI
49307-9443
US

V. Phone/Fax

Practice location:
  • Phone: 231-689-7156
  • Fax: 231-689-3869
Mailing address:
  • Phone: 231-679-0399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302038159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: