Provider Demographics
NPI:1225633514
Name:MARTIN, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MARTIN
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 1:272 LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1808
Mailing Address - Country:US
Mailing Address - Phone:207-400-7218
Mailing Address - Fax:
Practice Address - Street 1:295 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2018
Practice Address - Country:US
Practice Address - Phone:207-885-2098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4258183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist