Provider Demographics
NPI:1194195057
Name:AMMON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AMMON
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 1:12109 APPLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-6702
Mailing Address - Country:US
Mailing Address - Phone:760-240-5896
Mailing Address - Fax:760-240-3083
Practice Address - Street 1:12109 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-6702
Practice Address - Country:US
Practice Address - Phone:760-240-5896
Practice Address - Fax:760-240-3083
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist