=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689929903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORILEE DIZON PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2012
-----------------------------------------------------
Last Update Date | 04/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 BELFORT RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-296-3770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6623 WILLOW ST APT 5
-----------------------------------------------------
City | EL CERRITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94530-3659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | PS49215
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------