Provider Demographics
NPI:1407139124
Name:WALL, LISA LOUISE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LOUISE
Last Name:WALL
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 1:3909 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7965
Mailing Address - Country:US
Mailing Address - Phone:608-784-5302
Mailing Address - Fax:
Practice Address - Street 1:3909 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7965
Practice Address - Country:US
Practice Address - Phone:608-788-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10604-40183500000X
SD4357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist