Provider Demographics
NPI:1316374630
Name:KALLAS, LISA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KALLAS
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 1:7495 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2013
Mailing Address - Country:US
Mailing Address - Phone:801-213-9547
Mailing Address - Fax:801-213-9553
Practice Address - Street 1:7495 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2013
Practice Address - Country:US
Practice Address - Phone:801-213-9547
Practice Address - Fax:801-213-9553
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60292088183500000X, 1835P2201X
UT5601412-1701183500000X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist