Provider Demographics
NPI:1316389067
Name:CORRAL, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CORRAL
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 1:5034 KEVIN LN
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9741
Mailing Address - Country:US
Mailing Address - Phone:530-209-1837
Mailing Address - Fax:
Practice Address - Street 1:5034 KEVIN LN
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9741
Practice Address - Country:US
Practice Address - Phone:530-209-1837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98476183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician