Provider Demographics
NPI:1518306828
Name:HANSEN, LISA A (PHARM D)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10751 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1375
Mailing Address - Country:US
Mailing Address - Phone:208-373-5233
Mailing Address - Fax:208-373-5227
Practice Address - Street 1:10751 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1375
Practice Address - Country:US
Practice Address - Phone:208-373-5233
Practice Address - Fax:208-373-5227
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist