Provider Demographics
NPI:1336423987
Name:DEYOUNG, LISA (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEYOUNG
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 1:311 N BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3209
Mailing Address - Country:US
Mailing Address - Phone:660-665-3063
Mailing Address - Fax:660-665-8456
Practice Address - Street 1:311 N BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3209
Practice Address - Country:US
Practice Address - Phone:660-665-3063
Practice Address - Fax:660-665-8456
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007002494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist