Provider Demographics
NPI:1437556859
Name:CARR, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CARR
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 1:113 AMBLESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5346
Mailing Address - Country:US
Mailing Address - Phone:229-395-0302
Mailing Address - Fax:
Practice Address - Street 1:113 AMBLESIDE DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-5346
Practice Address - Country:US
Practice Address - Phone:229-395-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19406183500000X
FLPS29563183500000X
SC8748183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
328347OtherNABP