Provider Demographics
NPI:1518567064
Name:BAILEY, LISA ANN (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BAILEY
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 1:33071 OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7776
Mailing Address - Country:US
Mailing Address - Phone:574-780-0409
Mailing Address - Fax:269-683-7621
Practice Address - Street 1:2107 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4060
Practice Address - Country:US
Practice Address - Phone:269-683-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315164091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty