Provider Demographics
NPI:1104074509
Name:YOUNG, LISA RENE (PHARMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:RENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:820 S DAMEN AVE
Mailing Address - Street 2:DEPARTMENT OF PHARMACY (119)
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3728
Mailing Address - Country:US
Mailing Address - Phone:312-569-7949
Mailing Address - Fax:312-569-6185
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:DEPARTMENT OF PHARMACY (119)
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-7949
Practice Address - Fax:312-569-6185
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist