Provider Demographics
NPI:1093092199
Name:WIENCLAW, LISA ANNETTE (PHARM D)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNETTE
Last Name:WIENCLAW
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 GREENBRIER DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-2522
Mailing Address - Country:US
Mailing Address - Phone:319-321-5472
Mailing Address - Fax:
Practice Address - Street 1:830 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4101
Practice Address - Country:US
Practice Address - Phone:563-355-5345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19877OtherPHARMACY LICENSE