=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003292772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA VALLE PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2015
-----------------------------------------------------
Last Update Date | 08/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21201 E OCOTILLO ROAD
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-987-1615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3850 E SUNDANCE AVE
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-869-0733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S0202189
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------