MEDICARE: LISA ST. LOUIS PHARMD

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	RPH026255	GA
2	183500000X	Pharmacist	PS53115	FL

General Provider Information

NPI Number	:	1649608688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ST. LOUIS PHARMD

Provider Business Mailing Address
First Line	:	420 S NOVA RD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-0410
Country	:	US
Telephone Number	:	386-281-6633
Fax Number	:

Provider Business Practice Location Address
First Line	:	4036 S NOVA RD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-9276
Country	:	US
Telephone Number	:	386-304-8222
Fax Number	:

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

Provider Enumeration Date	:	10/30/2013
Last Update Date	:	03/23/2016

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Directions to “ LISA ST. LOUIS PHARMD” Practice Location

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