Provider Demographics
NPI:1144400714
Name:JOHNSON, LISA CAROL (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:CAROL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 STATE ROUTE 13
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-4516
Mailing Address - Country:US
Mailing Address - Phone:607-756-0421
Mailing Address - Fax:
Practice Address - Street 1:854 STATE ROUTE 13
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-4516
Practice Address - Country:US
Practice Address - Phone:607-756-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist