Healthcare Provider Details

I. General information

NPI: 1689262685
Provider Name (Legal Business Name): LISA MARIE AVERY PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-448-6177
  • Fax:
Mailing address:
  • Phone: 315-448-6177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number040788-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: