Provider Demographics
NPI:1538769567
Name:RISNER, TAMIKA DIANNE
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:DIANNE
Last Name:RISNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WESTWIND TRL
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1809
Mailing Address - Country:US
Mailing Address - Phone:502-507-8886
Mailing Address - Fax:
Practice Address - Street 1:1500 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7984
Practice Address - Country:US
Practice Address - Phone:270-763-0755
Practice Address - Fax:270-763-0768
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist