Healthcare Provider Details

I. General information

NPI: 1841986569
Provider Name (Legal Business Name): LISA BEDARD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA DEITERS PHARMD

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13655 RIVERPORT DR
MARYLAND HEIGHTS MO
63043-4812
US

IV. Provider business mailing address

703 JAMIE ST
BARTELSO IL
62218-1464
US

V. Phone/Fax

Practice location:
  • Phone: 618-322-3991
  • Fax: 844-243-3856
Mailing address:
  • Phone: 618-322-3991
  • Fax: 844-243-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051298440
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2014023127
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: