Provider Demographics
NPI:1073895058
Name:WIESNER, LISA JANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:WIESNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 WILMOT RD # 3268
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4618
Mailing Address - Country:US
Mailing Address - Phone:847-527-5636
Mailing Address - Fax:
Practice Address - Street 1:302 WILMOT RD # 3268
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4618
Practice Address - Country:US
Practice Address - Phone:847-527-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14439-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist