Provider Demographics
NPI:1417233370
Name:GRONNEBERG, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRONNEBERG
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 1:1305 CORPORATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1204
Mailing Address - Country:US
Mailing Address - Phone:612-777-4968
Mailing Address - Fax:
Practice Address - Street 1:1305 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1204
Practice Address - Country:US
Practice Address - Phone:612-777-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist