=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538665948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. PAMELA SUE LIZON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2018
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1612 MAIN STREET
-----------------------------------------------------
City | WELLSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-737-2037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1612 MAIN STREET
-----------------------------------------------------
City | WELLSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-737-2037
-----------------------------------------------------
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 | 4051
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------