Provider Demographics
NPI:1992080543
Name:BRADSHAW, LISA ANN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:BRADSHAW
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 1:2041 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3005
Mailing Address - Country:US
Mailing Address - Phone:334-712-6638
Mailing Address - Fax:334-712-6658
Practice Address - Street 1:2041 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3005
Practice Address - Country:US
Practice Address - Phone:334-712-6638
Practice Address - Fax:334-712-6658
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14165183500000X
FLPS37707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist