Provider Demographics
NPI:1295432003
Name:TIEDE-NEWLAND, LISA ANN (RPH)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:TIEDE-NEWLAND
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12466 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:HUNTSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44046-9737
Mailing Address - Country:US
Mailing Address - Phone:585-409-5883
Mailing Address - Fax:
Practice Address - Street 1:12466 FOREST RD
Practice Address - Street 2:
Practice Address - City:HUNTSBURG
Practice Address - State:OH
Practice Address - Zip Code:44046-9737
Practice Address - Country:US
Practice Address - Phone:585-409-5883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03316772183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist