Provider Demographics
NPI:1881686681
Name:DOUGLAS, LISA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 SHEPHERDS LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3059
Mailing Address - Country:US
Mailing Address - Phone:770-466-7585
Mailing Address - Fax:770-918-6525
Practice Address - Street 1:977B TAYLOR ST SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5357
Practice Address - Country:US
Practice Address - Phone:770-918-6508
Practice Address - Fax:770-918-6525
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016466183500000X
GARPH0164661835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No183500000XPharmacy Service ProvidersPharmacist