Provider Demographics
NPI:1568240844
Name:KISAMORE, LISA RENEE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:KISAMORE
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 1:400 GRAND PANAMA CIR APT 306
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3486
Mailing Address - Country:US
Mailing Address - Phone:850-545-3815
Mailing Address - Fax:
Practice Address - Street 1:11240 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2449
Practice Address - Country:US
Practice Address - Phone:850-233-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS66226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist