Provider Demographics
NPI:1497537070
Name:RANDOLPH, LISA M (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11420 W THEODORE TRECKER WAY
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1137
Mailing Address - Country:US
Mailing Address - Phone:414-727-5750
Mailing Address - Fax:
Practice Address - Street 1:11420 W THEODORE TRECKER WAY
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-1137
Practice Address - Country:US
Practice Address - Phone:414-727-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21418-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist