Provider Demographics
NPI:1548664261
Name:MOSTAFAVIFAR, LISA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MOSTAFAVIFAR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GLANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:410 W 10TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-3696
Mailing Address - Country:US
Mailing Address - Phone:614-366-7821
Mailing Address - Fax:
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-366-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH032308091835P0018X
WVRP00071021835P0018X
FLPS447721835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist