Provider Demographics
NPI:1154852713
Name:VON HEUVEL, LISA (RPH BS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VON HEUVEL
Suffix:
Gender:F
Credentials:RPH BS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH BS
Mailing Address - Street 1:3833 JACK NICKLAUS DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-3912
Mailing Address - Country:US
Mailing Address - Phone:830-370-6903
Mailing Address - Fax:
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5141
Practice Address - Country:US
Practice Address - Phone:575-521-2235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS009130183500000X
CA41948183500000X
TX42839183500000X
NMRP00007950183500000X
COPHA.0019484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist