Provider Demographics
NPI:1194113829
Name:LIES, LARISSA
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:LIES
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 1:7818 W 19TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-1496
Mailing Address - Country:US
Mailing Address - Phone:316-524-4228
Mailing Address - Fax:316-529-9020
Practice Address - Street 1:4747 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67216-1739
Practice Address - Country:US
Practice Address - Phone:316-524-4228
Practice Address - Fax:316-529-9020
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS148841835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist