Provider Demographics
NPI:1710232657
Name:ROBERTS, LISA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COSMOPOLIS
Mailing Address - State:WA
Mailing Address - Zip Code:98537-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:PROVIDENCE ST PETER HOSPITAL ANTICOAGULATION CLINIC
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-493-5369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00020356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist