Provider Demographics
NPI:1982044228
Name:LOPEZ, ELISSE NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELISSE
Middle Name:NICOLE
Last Name:LOPEZ
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 1:6295 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1100
Mailing Address - Country:US
Mailing Address - Phone:813-885-1792
Mailing Address - Fax:
Practice Address - Street 1:6295 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1100
Practice Address - Country:US
Practice Address - Phone:813-885-1792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS50390OtherFLORIDA DEPARTMENT OF HEALTH