Provider Demographics
NPI:1548772841
Name:EISSA, LOURIES
Entity Type:Individual
Prefix:
First Name:LOURIES
Middle Name:
Last Name:EISSA
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 1:2610 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-5948
Mailing Address - Country:US
Mailing Address - Phone:602-993-9900
Mailing Address - Fax:
Practice Address - Street 1:2610 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-5948
Practice Address - Country:US
Practice Address - Phone:602-993-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD09038484OtherDRIVER LICENSE