Provider Demographics
NPI:1376143347
Name:WALTER, LISA RENAE (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENAE
Last Name:WALTER
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 1:125 EMILYS WAY
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-9210
Mailing Address - Country:US
Mailing Address - Phone:304-563-8517
Mailing Address - Fax:
Practice Address - Street 1:3106 CANTON ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1316
Practice Address - Country:US
Practice Address - Phone:606-673-4912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03118910OtherOH BD OF PHARMACY
KY010496OtherKY BD OF PHARMACY
KY010496OtherKY BD OF PHARMACY