Provider Demographics
NPI:1164511481
Name:LISKA'S APOTHECARY SHOP, INC.
Entity type:Organization
Organization Name:LISKA'S APOTHECARY SHOP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:LISKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-855-0106
Mailing Address - Street 1:1840 MESQUITE AVE
Mailing Address - Street 2:SUITE E.
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5771
Mailing Address - Country:US
Mailing Address - Phone:928-855-0106
Mailing Address - Fax:928-855-7653
Practice Address - Street 1:1840 MESQUITE AVE
Practice Address - Street 2:SUITE E.
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5771
Practice Address - Country:US
Practice Address - Phone:928-855-0106
Practice Address - Fax:928-855-7653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X, 332B00000X, 3336C0002X
AZ13253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0765460001Medicare ID - Type Unspecified