Provider Demographics
NPI:1548557598
Name:MAXWELL, LISA A (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MAXWELL
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 1:2550 ADDISON AVE E
Mailing Address - Street 2:SUITE C
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6749
Mailing Address - Country:US
Mailing Address - Phone:208-814-7975
Mailing Address - Fax:208-814-7980
Practice Address - Street 1:2550 ADDISON AVE E
Practice Address - Street 2:SUITE C
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6749
Practice Address - Country:US
Practice Address - Phone:208-814-7975
Practice Address - Fax:208-814-7980
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist