Provider Demographics
NPI:1508153131
Name:RACKOW, LISA J (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:J
Last Name:RACKOW
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 1:3456 W SHORE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9699
Mailing Address - Country:US
Mailing Address - Phone:616-820-0094
Mailing Address - Fax:616-820-0094
Practice Address - Street 1:3456 W SHORE DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9699
Practice Address - Country:US
Practice Address - Phone:616-820-0094
Practice Address - Fax:616-820-0094
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist