Provider Demographics
NPI:1609270552
Name:BOCK, LISA (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOCK
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 1:4454 DARK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-9697
Mailing Address - Country:US
Mailing Address - Phone:541-779-2092
Mailing Address - Fax:
Practice Address - Street 1:2900 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8380
Practice Address - Country:US
Practice Address - Phone:541-789-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist