Provider Demographics
NPI:1992303473
Name:MILLER, LISA ANN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7937 W POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-3279
Mailing Address - Country:US
Mailing Address - Phone:262-352-4052
Mailing Address - Fax:
Practice Address - Street 1:7937 W POPLAR DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-3279
Practice Address - Country:US
Practice Address - Phone:262-352-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17814-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist