Provider Demographics
NPI:1861648222
Name:BOODRAM, LISA J (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:J
Last Name:BOODRAM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12411 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-2013
Mailing Address - Country:US
Mailing Address - Phone:718-738-3937
Mailing Address - Fax:
Practice Address - Street 1:501 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5807
Practice Address - Country:US
Practice Address - Phone:516-307-5895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-16
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051829OtherNEW YORK STATE LICENSE