Provider Demographics
NPI:1518567858
Name:LISSENDEN, UTAHVY
Entity Type:Individual
Prefix:
First Name:UTAHVY
Middle Name:
Last Name:LISSENDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:UTAHVY
Other - Middle Name:
Other - Last Name:SETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 COBB PKWY S
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 COBB PKWY S
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9209
Practice Address - Country:US
Practice Address - Phone:678-285-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023292183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist