Provider Demographics
NPI:1457660698
Name:LAFOLLETTE, LISA (RPH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:LAFOLLETTE
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 1:404 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4910
Mailing Address - Country:US
Mailing Address - Phone:910-484-1106
Mailing Address - Fax:910-484-1969
Practice Address - Street 1:404 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4910
Practice Address - Country:US
Practice Address - Phone:910-484-1106
Practice Address - Fax:910-484-1969
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38-0456365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0265637Medicaid
NC1093818775OtherNPI