Healthcare Provider Details

I. General information

NPI: 1659786184
Provider Name (Legal Business Name): LISA MARIE CILLESSEN PHARMD, RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

IV. Provider business mailing address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

V. Phone/Fax

Practice location:
  • Phone: 417-831-0150
  • Fax:
Mailing address:
  • Phone: 417-831-0150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03233944-2
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH235251
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015027215
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: