Provider Demographics
NPI:1679318034
Name:LIPA, RENEA
Entity type:Individual
Prefix:
First Name:RENEA
Middle Name:
Last Name:LIPA
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 1:2904 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3010
Mailing Address - Country:US
Mailing Address - Phone:318-398-2100
Mailing Address - Fax:318-387-7682
Practice Address - Street 1:2904 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3010
Practice Address - Country:US
Practice Address - Phone:318-398-2100
Practice Address - Fax:318-387-7682
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist