Provider Demographics
NPI:1205105335
Name:HIBBERD, LISA ANNE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:HIBBERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 IRVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-9591
Mailing Address - Country:US
Mailing Address - Phone:804-577-0236
Mailing Address - Fax:
Practice Address - Street 1:6908 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5121
Practice Address - Country:US
Practice Address - Phone:804-693-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2013-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist