Healthcare Provider Details

I. General information

NPI: 1497487359
Provider Name (Legal Business Name): LISA MARIE GREENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 1ST ST NE
LAKE PRESTON SD
57249-2334
US

IV. Provider business mailing address

PO BOX 71
LAKE PRESTON SD
57249-0071
US

V. Phone/Fax

Practice location:
  • Phone: 605-860-0021
  • Fax:
Mailing address:
  • Phone: 605-860-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6961
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: