Provider Demographics
NPI:1114107216
Name:LIZZA PHARMACEUTICAL LLC
Entity type:Organization
Organization Name:LIZZA PHARMACEUTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-494-7493
Mailing Address - Street 1:40 WIGHT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2148
Mailing Address - Country:US
Mailing Address - Phone:667-408-7767
Mailing Address - Fax:724-437-7808
Practice Address - Street 1:278 MCCLELLANDTOWN ROAD
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401
Practice Address - Country:US
Practice Address - Phone:724-437-5070
Practice Address - Fax:724-437-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4816983336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102091796001Medicaid
2082220OtherPK