Provider Demographics
NPI:1104124098
Name:MARTIN, LISA S (RPH)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:S
Last Name:MARTIN
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 1:906 JAYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5605
Mailing Address - Country:US
Mailing Address - Phone:704-847-4792
Mailing Address - Fax:
Practice Address - Street 1:3345 PINEVILLE MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-9304
Practice Address - Country:US
Practice Address - Phone:704-543-6055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09228183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist