MEDICARE: LISA M LIBBY RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS0025889	FL

General Provider Information

NPI Number	:	1497036917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M LIBBY RPH

Provider Business Mailing Address
First Line	:	3004 S ATLANTIC AVE
Second Line	:
City	:	DAYTONA BEACH SHORES
State	:	FL
Zip	:	32118-6102
Country	:	US
Telephone Number	:	386-788-6344
Fax Number	:	386-788-8703

Provider Business Practice Location Address
First Line	:	3004 S ATLANTIC AVE
Second Line	:
City	:	DAYTONA BEACH SHORES
State	:	FL
Zip	:	32118-6102
Country	:	US
Telephone Number	:	386-788-6344
Fax Number	:	386-788-8703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	08/30/2011

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