Provider Demographics
NPI:1144436502
Name:WITTER, LISA MARY (RPH)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARY
Last Name:WITTER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARY
Other - Last Name:EVERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1028 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1532
Mailing Address - Country:US
Mailing Address - Phone:608-375-2140
Mailing Address - Fax:
Practice Address - Street 1:1028 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1532
Practice Address - Country:US
Practice Address - Phone:608-375-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist