Provider Demographics
NPI:1457632564
Name:CIESKI, LISA ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:CIESKI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15575 E 127TH ST
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4433
Mailing Address - Country:US
Mailing Address - Phone:306-257-9250
Mailing Address - Fax:630-910-3687
Practice Address - Street 1:15575 E 127TH ST
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4433
Practice Address - Country:US
Practice Address - Phone:630-257-9250
Practice Address - Fax:630-910-3687
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-036016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362127039065Medicaid