Provider Demographics
NPI:1003028432
Name:WHITAKER, LISA LEE (RPH, CDM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LEE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:RPH, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4361
Mailing Address - Country:US
Mailing Address - Phone:860-621-8684
Mailing Address - Fax:860-621-8684
Practice Address - Street 1:922 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3419
Practice Address - Country:US
Practice Address - Phone:203-271-0282
Practice Address - Fax:203-272-1459
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist