Provider Demographics
NPI:1124575477
Name:EGE, LISA MICHELLE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:EGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W PEACE RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8913
Mailing Address - Country:US
Mailing Address - Phone:815-895-9435
Mailing Address - Fax:
Practice Address - Street 1:220 W PEACE RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-8913
Practice Address - Country:US
Practice Address - Phone:815-895-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.299749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist