Provider Demographics
NPI:1689998932
Name:BASH, LISA MERYL
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MERYL
Last Name:BASH
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 1:340 E 64TH ST
Mailing Address - Street 2:5K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7503
Mailing Address - Country:US
Mailing Address - Phone:212-686-0713
Mailing Address - Fax:
Practice Address - Street 1:1494 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-8816
Practice Address - Country:US
Practice Address - Phone:212-472-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041463-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist