Provider Demographics
NPI:1467635060
Name:WELLER, LISA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:WELLER
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 1:9241 SHELLEY DR
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2623
Mailing Address - Country:US
Mailing Address - Phone:315-206-4071
Mailing Address - Fax:
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1001
Practice Address - Country:US
Practice Address - Phone:315-798-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist