Provider Demographics
NPI:1245711993
Name:LU, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5468 ASHTON MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-5214
Mailing Address - Country:US
Mailing Address - Phone:941-549-3619
Mailing Address - Fax:
Practice Address - Street 1:11600 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4567
Practice Address - Country:US
Practice Address - Phone:239-437-3681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL58245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist