Provider Demographics
NPI:1710260526
Name:BLOEBAUM, LISA MICHELLE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:BLOEBAUM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:812-882-3896
Mailing Address - Fax:812-882-0978
Practice Address - Street 1:505 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591
Practice Address - Country:US
Practice Address - Phone:812-882-3896
Practice Address - Fax:812-882-0978
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021096A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist