Provider Demographics
NPI:1568121614
Name:WILSON, LISA L (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:WILSON
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 1:10616 CLAYTON ALLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2495
Mailing Address - Country:US
Mailing Address - Phone:502-435-7112
Mailing Address - Fax:
Practice Address - Street 1:4926 CANE RUN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1149
Practice Address - Country:US
Practice Address - Phone:502-449-5168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist