Provider Demographics
NPI:1952791626
Name:MERRY, LISA MARIE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:MERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CANTRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2007 E BATAAN DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-3607
Mailing Address - Country:US
Mailing Address - Phone:937-305-6561
Mailing Address - Fax:
Practice Address - Street 1:4341 FEEDWIRE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-3970
Practice Address - Country:US
Practice Address - Phone:937-439-9357
Practice Address - Fax:937-310-8296
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH510107010080712183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician