Provider Demographics
NPI:1558955658
Name:MAKDISY, LIZA
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:MAKDISY
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 1:11706 EXPOSITION BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1337
Mailing Address - Country:US
Mailing Address - Phone:310-663-9311
Mailing Address - Fax:
Practice Address - Street 1:500 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1404
Practice Address - Country:US
Practice Address - Phone:310-260-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist