Provider Demographics
NPI:1598373441
Name:IVERSON, LISA K
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:IVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 LOWER ROY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-2736
Mailing Address - Country:US
Mailing Address - Phone:121-883-8869
Mailing Address - Fax:
Practice Address - Street 1:30833 N STAR DR STE 2
Practice Address - Street 2:
Practice Address - City:BREEZY POINT
Practice Address - State:MN
Practice Address - Zip Code:56472-4407
Practice Address - Country:US
Practice Address - Phone:218-562-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist