Provider Demographics
NPI:1811355688
Name:FOWLER, LISA WILCOX (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:WILCOX
Last Name:FOWLER
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 1:3545 CHAIN BRIDGE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2708
Mailing Address - Country:US
Mailing Address - Phone:571-732-4633
Mailing Address - Fax:571-732-4643
Practice Address - Street 1:3545 CHAIN BRIDGE RD STE 102
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2708
Practice Address - Country:US
Practice Address - Phone:571-732-4633
Practice Address - Fax:571-732-4643
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03331630183500000X
NY057706183500000X
MS08982183500000X
AL19233183500000X
AZS021905183500000X
KS1-117754183500000X
KY022865183500000X
LAPST.021598183500000X
MD24188183500000X
MAPH236963183500000X
MI5302414520183500000X
NE17573183500000X
NV22963183500000X
OKR-19700183500000X
VA0202220418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist