Basic Information
Provider Information
NPI: 1003139684
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MARTIN
FirstName: LISA
MiddleName: BROWN
NamePrefix:  
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1710 SHELBY OAKS DR N
Address2: STE 1
City: MEMPHIS
State: TN
PostalCode: 381347403
CountryCode: US
TelephoneNumber: 9012015468
FaxNumber:  
Practice Location
Address1: 1710 SHELBY OAKS DR N
Address2: STE 1
City: MEMPHIS
State: TN
PostalCode: 381347403
CountryCode: US
TelephoneNumber: 9012015468
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/10/2010
LastUpdateDate: 10/27/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X10607KYN Pharmacy Service ProvidersPharmacist 
183500000X09888MSY Pharmacy Service ProvidersPharmacist 
183500000X22858TNN Pharmacy Service ProvidersPharmacist 

No ID Information.


Home