Provider Demographics
NPI:1851403182
Name:LISBERG, TIMOTHY A JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:LISBERG
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-1103
Mailing Address - Country:US
Mailing Address - Phone:585-530-3570
Mailing Address - Fax:585-530-2149
Practice Address - Street 1:821 N CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-1103
Practice Address - Country:US
Practice Address - Phone:585-530-3570
Practice Address - Fax:585-530-2149
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist