Provider Demographics
NPI:1184225062
Name:WILSON, LISA DIANE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 OVERCUP DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3706
Mailing Address - Country:US
Mailing Address - Phone:501-772-1679
Mailing Address - Fax:
Practice Address - Street 1:5600 LANDERS ROAD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72117
Practice Address - Country:US
Practice Address - Phone:501-955-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist