Provider Demographics
NPI:1417161829
Name:WALWORTH, LISA A (RPH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:WALWORTH
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 1:6173 WALNUT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1955
Mailing Address - Country:US
Mailing Address - Phone:716-741-6916
Mailing Address - Fax:
Practice Address - Street 1:400 FOREST AVE
Practice Address - Street 2:PHARMACY DEPARTMENT
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1207
Practice Address - Country:US
Practice Address - Phone:716-816-2493
Practice Address - Fax:716-816-2496
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist