Provider Demographics
NPI:1477607828
Name:BOOTHBY, LISA ANNE (PHARMD, BCPS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:BOOTHBY
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 E LOU LN
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-8652
Mailing Address - Country:US
Mailing Address - Phone:765-460-5066
Mailing Address - Fax:
Practice Address - Street 1:275 W 12TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1638
Practice Address - Country:US
Practice Address - Phone:765-472-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0206501835P1200X
FLPS349541835P1200X
IN26023438A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy