Provider Demographics
NPI:1033944475
Name:LIS, AGNIESZKA (RPH)
Entity type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:LIS
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 1:8402 98TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1735
Mailing Address - Country:US
Mailing Address - Phone:646-637-2010
Mailing Address - Fax:
Practice Address - Street 1:987 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-6776
Practice Address - Country:US
Practice Address - Phone:718-349-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047079-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist