Provider Demographics
NPI:1386724987
Name:VICK, LISA M (PHARM D)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:VICK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1981 GRIMES GOLDEN DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-1703
Mailing Address - Country:US
Mailing Address - Phone:419-729-0651
Mailing Address - Fax:
Practice Address - Street 1:730 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2900
Practice Address - Country:US
Practice Address - Phone:734-240-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036318183500000X
OH03326712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist