Provider Demographics
NPI:1679140826
Name:SPY, JALISA L
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:L
Last Name:SPY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 SUPERIOR AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2054
Mailing Address - Country:US
Mailing Address - Phone:614-999-3665
Mailing Address - Fax:
Practice Address - Street 1:397 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1409
Practice Address - Country:US
Practice Address - Phone:614-999-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy