=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568240844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA RENEE KISAMORE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11240 PANAMA CITY BEACH PKWY
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-233-4590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 GRAND PANAMA CIR APT 306
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-3486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-545-3815
-----------------------------------------------------
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 | PS66226
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------