Provider Demographics
NPI:1265859847
Name:EZZELL-WEEKS, LISA B
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:EZZELL-WEEKS
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 1:308 NC 55 WEST
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365
Mailing Address - Country:US
Mailing Address - Phone:919-658-2608
Mailing Address - Fax:919-658-2807
Practice Address - Street 1:308 NC 55 WEST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365
Practice Address - Country:US
Practice Address - Phone:919-658-2608
Practice Address - Fax:919-658-2807
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0965741Medicaid