Provider Demographics
NPI:1295002095
Name:CARLISLE, LAURA G (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 LAC LAVON DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6398
Mailing Address - Country:US
Mailing Address - Phone:651-249-8716
Mailing Address - Fax:
Practice Address - Street 1:14700 LAC LAVON DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306
Practice Address - Country:US
Practice Address - Phone:952-432-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15770-40183500000X
MN122240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1295002095Medicaid