Provider Demographics
NPI:1275133902
Name:STEPHENS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STEPHENS
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 1:1612 LAKEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-8004
Mailing Address - Country:US
Mailing Address - Phone:304-481-3050
Mailing Address - Fax:
Practice Address - Street 1:1100 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1049
Practice Address - Country:US
Practice Address - Phone:304-295-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist