Provider Demographics
NPI:1497342430
Name:KERVICK, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KERVICK
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 1:504 S OXFORD VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030-2615
Mailing Address - Country:US
Mailing Address - Phone:215-945-5720
Mailing Address - Fax:215-945-3093
Practice Address - Street 1:504 S OXFORD VALLEY RD
Practice Address - Street 2:
Practice Address - City:FAIRLESS HILLS
Practice Address - State:PA
Practice Address - Zip Code:19030-2615
Practice Address - Country:US
Practice Address - Phone:215-945-5720
Practice Address - Fax:215-945-3093
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP044750L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist