Provider Demographics
NPI:1740343813
Name:RIIS, LARA J (PHARMD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:J
Last Name:RIIS
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 1:38888 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012-7508
Mailing Address - Country:US
Mailing Address - Phone:651-583-3551
Mailing Address - Fax:
Practice Address - Street 1:301 RIVER STREET
Practice Address - Street 2:PHARMACY
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020
Practice Address - Country:US
Practice Address - Phone:715-294-5624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14578-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33059800Medicaid