Provider Demographics
NPI:1710440904
Name:GABRIELSON, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GABRIELSON
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 1:11208 WHITEWATER DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5309
Mailing Address - Country:US
Mailing Address - Phone:701-893-8607
Mailing Address - Fax:
Practice Address - Street 1:9925 HUDSON PL
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9461
Practice Address - Country:US
Practice Address - Phone:651-702-7980
Practice Address - Fax:651-702-7983
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120451183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120451OtherMN BOARD OF PHARMACY