Provider Demographics
NPI:1548583495
Name:DIDOMENICO, LISA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 SALISBURY RD
Mailing Address - Street 2:
Mailing Address - City:BEMUS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:14712-9747
Mailing Address - Country:US
Mailing Address - Phone:716-386-5431
Mailing Address - Fax:
Practice Address - Street 1:110 S WORK ST
Practice Address - Street 2:
Practice Address - City:FALCONER
Practice Address - State:NY
Practice Address - Zip Code:14733-1434
Practice Address - Country:US
Practice Address - Phone:716-665-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist