Provider Demographics
NPI:1104915404
Name:LISKA, JOHN FRANKLIN (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:FRANKLIN
Last Name:LISKA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0765460001Medicare ID - Type Unspecified