Provider Demographics
NPI:1245071794
Name:MATTES, LISA (PHARMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MATTES
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 1:1608 RIVERVIEW LN
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:662 N 4TH ST
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2123
Practice Address - Country:US
Practice Address - Phone:715-453-2741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14912-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist