Provider Demographics
NPI:1770910853
Name:BABIAK, LISA (PHARMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BABIAK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 PREAKNESS DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4729
Mailing Address - Country:US
Mailing Address - Phone:208-514-5974
Mailing Address - Fax:
Practice Address - Street 1:2655 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4721
Practice Address - Country:US
Practice Address - Phone:208-345-8729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6593183500000X
AK1999183500000X
WAPH60302601183500000X
TX52575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist