Provider Demographics
NPI:1669651840
Name:LISSMART MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:LISSMART MEDICAL SUPPLIES INC
Other - Org Name:LISSMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISVET
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-417-9860
Mailing Address - Street 1:4579 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-6311
Mailing Address - Country:US
Mailing Address - Phone:813-374-2452
Mailing Address - Fax:813-374-2453
Practice Address - Street 1:4579 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-6311
Practice Address - Country:US
Practice Address - Phone:813-374-2452
Practice Address - Fax:813-374-2453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2013-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
FLPH230403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032313600Medicaid
2010231OtherPK
FL032313600Medicaid