Provider Demographics
NPI:1982820528
Name:MALLOTT, LISA J (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:MALLOTT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 62ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-3469
Mailing Address - Country:US
Mailing Address - Phone:360-754-4340
Mailing Address - Fax:
Practice Address - Street 1:207 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4404
Practice Address - Country:US
Practice Address - Phone:360-426-4626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH15636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist