Provider Demographics
NPI:1639443195
Name:HAACKER, LISA MARIE (PHARMACY TECHNIEIAN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HAACKER
Suffix:
Gender:F
Credentials:PHARMACY TECHNIEIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11912 NE FOURTH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662
Mailing Address - Country:US
Mailing Address - Phone:360-944-8368
Mailing Address - Fax:360-944-6555
Practice Address - Street 1:11912 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662
Practice Address - Country:US
Practice Address - Phone:360-944-8368
Practice Address - Fax:360-944-6555
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA 00062276183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVA 00062276OtherWASHINGTON STATE