Provider Demographics
NPI:1174818322
Name:BHATTA, LISA L (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:L
Last Name:BHATTA
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 1:1860 N RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5416
Mailing Address - Country:US
Mailing Address - Phone:815-385-1280
Mailing Address - Fax:815-385-1280
Practice Address - Street 1:1860 N. RICHMOND RD.
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60051-5416
Practice Address - Country:US
Practice Address - Phone:815-385-1280
Practice Address - Fax:815-385-1280
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290103183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist