Provider Demographics
NPI:1477154037
Name:HAYNES, LISA ROBBINS
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROBBINS
Last Name:HAYNES
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 1:1701 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-8625
Mailing Address - Country:US
Mailing Address - Phone:270-274-4564
Mailing Address - Fax:
Practice Address - Street 1:1701 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8625
Practice Address - Country:US
Practice Address - Phone:270-274-4564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0094493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy