=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629421169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA HUNTSMAN RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2016
-----------------------------------------------------
Last Update Date | 07/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6361 PECAN ORCHARD CT
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76179-9291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-728-3348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6361 PECAN ORCHARD CT
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76179-9291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-728-3348
-----------------------------------------------------
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 | 31623
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 1-17088
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | T-010805
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | CP11410
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PST.019191
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------