Provider Demographics
NPI:1174967608
Name:FEAGANS, LISA RAE (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:FEAGANS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 W NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2317
Mailing Address - Country:US
Mailing Address - Phone:719-564-0491
Mailing Address - Fax:719-560-7222
Practice Address - Street 1:3050 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2317
Practice Address - Country:US
Practice Address - Phone:719-564-0491
Practice Address - Fax:719-560-7222
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist