Provider Demographics
NPI:1497936462
Name:MARTIN, LISA CLAYVILLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CLAYVILLE
Last Name:MARTIN
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 1:710 DURANGO LOOP ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-5685
Mailing Address - Country:US
Mailing Address - Phone:410-251-2349
Mailing Address - Fax:
Practice Address - Street 1:960 BACK STAGE LN
Practice Address - Street 2:
Practice Address - City:LAKE BUENA VISTA
Practice Address - State:FL
Practice Address - Zip Code:32830-8472
Practice Address - Country:US
Practice Address - Phone:407-934-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42543183500000X
MD18358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist