Provider Demographics
NPI:1063406833
Name:GARDNER, LISA M (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:GARDNER
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:PO BOX 1390
Mailing Address - Street 2:
Mailing Address - City:FLIPPIN
Mailing Address - State:AR
Mailing Address - Zip Code:72634-1390
Mailing Address - Country:US
Mailing Address - Phone:870-493-7367
Mailing Address - Fax:
Practice Address - Street 1:109 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FLIPPIN
Practice Address - State:AR
Practice Address - Zip Code:72634-8613
Practice Address - Country:US
Practice Address - Phone:501-313-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR08467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD08467OtherAR STATE BOARD OF PHARMACY