Provider Demographics
NPI:1073033726
Name:DIEPHOUSE, LISA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DIEPHOUSE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1793
Mailing Address - Country:US
Mailing Address - Phone:616-772-4685
Mailing Address - Fax:616-772-9526
Practice Address - Street 1:115 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1735
Practice Address - Country:US
Practice Address - Phone:616-772-4685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty