Provider Demographics
NPI:1801483797
Name:MCCLANAHAN, LISA CAROL
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CAROL
Last Name:MCCLANAHAN
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 1:16641 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VA
Mailing Address - Zip Code:23192-2660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16641 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VA
Practice Address - Zip Code:23192-2660
Practice Address - Country:US
Practice Address - Phone:804-883-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA10086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist