=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568852168
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. LISA MARIE TIRABASSI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7500 COMMONS BLVD
-----------------------------------------------------
City | VICTOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14564-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-465-8966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7500 COMMONS BLVD
-----------------------------------------------------
City | VICTOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14564-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-465-8966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 530107010118549
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------