=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730854035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE LAVISKA PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2021
-----------------------------------------------------
Last Update Date | 09/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 BRIARCLIFF CIR
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-8690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-473-8489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 BRIARCLIFF CIR
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-8690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-473-8489
-----------------------------------------------------
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 | PS62905
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------