Provider Demographics
NPI:1255677944
Name:SANDBO, LISA MARLIS (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARLIS
Last Name:SANDBO
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 1:342 MASSACHUSETTS AVENUE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204
Mailing Address - Country:US
Mailing Address - Phone:317-631-6000
Mailing Address - Fax:317-631-6004
Practice Address - Street 1:342 MASSACHUSETTS AVENUE
Practice Address - Street 2:SUITE 103
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204
Practice Address - Country:US
Practice Address - Phone:317-631-6000
Practice Address - Fax:317-631-6004
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017201A183500000X
CA43798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43798OtherSTATE LICENSE
IN26017201AOtherSTATE LICENSE