Provider Demographics
NPI:1134721368
Name:NELMS, LISA (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NELMS
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 1:14167 BROOKMAN RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:VA
Mailing Address - Zip Code:22972-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 ABBEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3543
Practice Address - Country:US
Practice Address - Phone:434-244-4301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902839251OtherGIANT
VA1902839251Medicaid