Provider Demographics
NPI:1578166856
Name:MARTIN, LISA S I (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:S
Last Name:MARTIN
Suffix:I
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 1:15420 STILLWELL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44046-8774
Mailing Address - Country:US
Mailing Address - Phone:440-636-5778
Mailing Address - Fax:
Practice Address - Street 1:296 CENTER ST
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1172
Practice Address - Country:US
Practice Address - Phone:440-286-9445
Practice Address - Fax:440-286-4419
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-19334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist