Provider Demographics
NPI:1790914489
Name:LIS, ERIC RONALD
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:RONALD
Last Name:LIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE F6/133
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:608-263-1284
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE # F6133
Practice Address - Street 2:COMPLIANCE MC 2433
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-662-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15544-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist