Provider Demographics
NPI:1134173784
Name:LISTA, JOEL CHANDLER (RPH)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:CHANDLER
Last Name:LISTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 SCHOONER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8934
Mailing Address - Country:US
Mailing Address - Phone:843-745-8650
Mailing Address - Fax:843-554-5453
Practice Address - Street 1:3725 RIVERS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7038
Practice Address - Country:US
Practice Address - Phone:843-745-8650
Practice Address - Fax:843-554-5453
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5947OtherRPH