Basic Information
| Provider Information | |||||||||
| NPI: | 1154366094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISH | ||||||||
| FirstName: | ALISA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMACIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORDON | ||||||||
| OtherFirstName: | ALISA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 255 ENTERPRISE BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540888 | ||||||||
| FaxNumber: | 8644541130 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 GROVE RD | ||||||||
| Address2: | EMPLOYEE PAVILION | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296055611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644558910 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 10927 | SC | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 10927 | 01 | SC | PHARMACIST LICENSE | OTHER |