Provider Demographics
NPI:1538443510
Name:PEABODY, LISA ANN (RPH)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:ANN
Last Name:PEABODY
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 1:22515 GREATER MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2040
Mailing Address - Country:US
Mailing Address - Phone:586-447-4368
Mailing Address - Fax:586-447-4374
Practice Address - Street 1:22515 GREATER MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2040
Practice Address - Country:US
Practice Address - Phone:586-447-4368
Practice Address - Fax:586-447-4374
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8675309Medicaid