Basic Information
| Provider Information | |||||||||
| NPI: | 1558905026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONCEPCION | ||||||||
| FirstName: | JEISSA | ||||||||
| MiddleName: | LIZANDRA | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7697 NW 19TH CT | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330240921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546511665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3791 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330554510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059141974 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2019 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS35754 | FL | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.