Provider Demographics
NPI:1942710751
Name:VAN LIZZEN, DANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:VAN LIZZEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8125 FLETCHER PKWY
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2934
Mailing Address - Country:US
Mailing Address - Phone:619-667-8520
Mailing Address - Fax:
Practice Address - Street 1:8125 FLETCHER PKWY
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2934
Practice Address - Country:US
Practice Address - Phone:619-667-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist