Provider Demographics
NPI:1376306928
Name:WALTZ, LISA MICHELLE (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:WALTZ
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:W278N7278 MILLPOND WAY
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8236
Mailing Address - Country:US
Mailing Address - Phone:262-337-2813
Mailing Address - Fax:
Practice Address - Street 1:301 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1900
Practice Address - Country:US
Practice Address - Phone:608-647-8806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11672-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist