Provider Demographics
NPI:1518309194
Name:FISHER, VICKI LYNN (RPH)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LYNN
Last Name:FISHER
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 1:1140 HERITAGE HL
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-1810
Mailing Address - Country:US
Mailing Address - Phone:361-550-4612
Mailing Address - Fax:
Practice Address - Street 1:7501 SAN DARIO AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-7207
Practice Address - Country:US
Practice Address - Phone:956-722-1205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21671OtherPHARMACY STATE LISCENE NUMBER