Provider Demographics
NPI:1104479039
Name:LISKA'S APOTHECARY SHOP, INC.
Entity type:Organization
Organization Name:LISKA'S APOTHECARY SHOP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:LISKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-855-0106
Mailing Address - Street 1:1840 MESQUITE AVE., STE. E
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:982-855-0106
Mailing Address - Fax:928-855-7653
Practice Address - Street 1:1840 MESQUITE AVE., STE. E
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:982-855-0106
Practice Address - Fax:928-855-7653
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LISKA'S APOTHECARY SHOP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ300012Medicaid