1164511481 NPI number — LISKA'S APOTHECARY SHOP, INC.

Table of content: (NPI 1164511481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164511481 NPI number — LISKA'S APOTHECARY SHOP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISKA'S APOTHECARY SHOP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LISKA'S APOTHECARY SHOP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164511481
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1840 MESQUITE AVE
Provider Second Line Business Mailing Address:
SUITE E.
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86403-5771
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-855-0106
Provider Business Mailing Address Fax Number:
928-855-7653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 MESQUITE AVE
Provider Second Line Business Practice Location Address:
SUITE E.
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-855-0106
Provider Business Practice Location Address Fax Number:
928-855-7653
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LISKA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
ADRIAN
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
928-855-0106

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1325 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)