Provider Demographics
NPI:1396187308
Name:MAI, LISA EAST
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:EAST
Last Name:MAI
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 1:19200 SW MARTINAZZI AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-6357
Mailing Address - Country:US
Mailing Address - Phone:503-691-4233
Mailing Address - Fax:
Practice Address - Street 1:19200 SW MARTINAZZI AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6357
Practice Address - Country:US
Practice Address - Phone:503-691-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0010363183500000X
OR103631835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist