Provider Demographics
NPI:1417225731
Name:MLODZIK, LISA MARIE (PHARM D, CGP, FASCP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:MLODZIK
Suffix:
Gender:F
Credentials:PHARM D, CGP, FASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 30TH CT
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3064
Mailing Address - Country:US
Mailing Address - Phone:262-553-2145
Mailing Address - Fax:262-553-2145
Practice Address - Street 1:1316 30TH CT
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3064
Practice Address - Country:US
Practice Address - Phone:262-553-2145
Practice Address - Fax:262-553-2145
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122491835P0018X
MN114364-91835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy