Provider Demographics
NPI:1861675696
Name:MASON, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MASON
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 1:12 MALLARDS LNDG N
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188-1046
Mailing Address - Country:US
Mailing Address - Phone:518-237-3063
Mailing Address - Fax:
Practice Address - Street 1:863 2ND AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-1901
Practice Address - Country:US
Practice Address - Phone:518-235-5530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-15
Last Update Date:2007-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist