Healthcare Provider Details

I. General information

NPI: 1336423987
Provider Name (Legal Business Name): LISA DEYOUNG RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N BALTIMORE ST
KIRKSVILLE MO
63501-3209
US

IV. Provider business mailing address

311 N BALTIMORE ST
KIRKSVILLE MO
63501-3209
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-3063
  • Fax: 660-665-8456
Mailing address:
  • Phone: 660-665-3063
  • Fax: 660-665-8456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2007002494
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: