Provider Demographics
NPI:1922584242
Name:HOSTUTLER, LISA KATE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KATE
Last Name:HOSTUTLER
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 1:805 DES MOINES AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5275
Mailing Address - Country:US
Mailing Address - Phone:304-216-2965
Mailing Address - Fax:
Practice Address - Street 1:1851 EARL L. CORE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-296-0657
Practice Address - Fax:304-296-8161
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0010567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist