Provider Demographics
NPI:1972851871
Name:WIRTH, LISA ANTOINETTE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANTOINETTE
Last Name:WIRTH
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 1:1456 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2700
Mailing Address - Country:US
Mailing Address - Phone:419-529-4602
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRPH.03132018-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist