Provider Demographics
NPI:1659436053
Name:MCDONALD, LISA G (RPH, CDM)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:G
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:RPH, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 SPARTA RD
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1859
Mailing Address - Country:US
Mailing Address - Phone:478-552-6114
Mailing Address - Fax:478-552-6119
Practice Address - Street 1:528 SPARTA RD
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1859
Practice Address - Country:US
Practice Address - Phone:478-552-6114
Practice Address - Fax:478-552-6119
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA017231OtherSTATE PHARMACIST'S LICENS