Provider Demographics
NPI:1649874314
Name:WHEATON, LISA CHRISTINE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINE
Last Name:WHEATON
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 1:10 SARAHS WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-3161
Mailing Address - Country:US
Mailing Address - Phone:508-999-0790
Mailing Address - Fax:
Practice Address - Street 1:10 SARAHS WAY
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-3161
Practice Address - Country:US
Practice Address - Phone:508-999-0790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist