Provider Demographics
NPI:1508464595
Name:OSTLUND, LISA S (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:OSTLUND
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 1:8051 MAGNOLIA LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7177
Mailing Address - Country:US
Mailing Address - Phone:612-387-9211
Mailing Address - Fax:
Practice Address - Street 1:8000 LAKELAND AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2403
Practice Address - Country:US
Practice Address - Phone:763-424-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist