Provider Demographics
NPI:1811007008
Name:BRANDT, LISA ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:BRANDT
Suffix:
Gender:F
Credentials:RPH
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 966
Mailing Address - Street 2:124 EAGLE POINT RD
Mailing Address - City:COLERAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55722-0966
Mailing Address - Country:US
Mailing Address - Phone:218-245-2241
Mailing Address - Fax:218-326-2526
Practice Address - Street 1:304 POKEGAMA AVE . N.
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-2635
Practice Address - Fax:218-326-2526
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115207-0183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist