Provider Demographics
NPI:1386357655
Name:HERGAN, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:HERGAN
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 1:4415 W SOUTHERN ST
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-8626
Mailing Address - Country:US
Mailing Address - Phone:570-778-9988
Mailing Address - Fax:
Practice Address - Street 1:1298 E NORVELL BRYANT HWY STE D
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442-4992
Practice Address - Country:US
Practice Address - Phone:352-419-8949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist