Provider Demographics
NPI:1861096711
Name:AYALA, LISETTE (RPH)
Entity type:Individual
Prefix:DR
First Name:LISETTE
Middle Name:
Last Name:AYALA
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 1:8712 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2708
Mailing Address - Country:US
Mailing Address - Phone:773-933-9200
Mailing Address - Fax:773-933-9206
Practice Address - Street 1:8712 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2708
Practice Address - Country:US
Practice Address - Phone:773-933-9200
Practice Address - Fax:773-933-9206
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist