Provider Demographics
NPI:1235686502
Name:DOMMERT, LISA VENABLE (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:VENABLE
Last Name:DOMMERT
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 1:5705 COURTLAND PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-2665
Mailing Address - Country:US
Mailing Address - Phone:318-664-2852
Mailing Address - Fax:
Practice Address - Street 1:1422 MACARTHUR DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-4022
Practice Address - Country:US
Practice Address - Phone:318-442-0512
Practice Address - Fax:318-443-4205
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-05
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist