Provider Demographics
NPI:1841986569
Name:BEDARD, LISA (PHARMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BEDARD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DEITERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:703 JAMIE ST
Mailing Address - Street 2:
Mailing Address - City:BARTELSO
Mailing Address - State:IL
Mailing Address - Zip Code:62218-1464
Mailing Address - Country:US
Mailing Address - Phone:618-322-3991
Mailing Address - Fax:844-243-3856
Practice Address - Street 1:13655 RIVERPORT DR
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-4812
Practice Address - Country:US
Practice Address - Phone:618-322-3991
Practice Address - Fax:844-243-3856
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298440183500000X
MO2014023127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist