Provider Demographics
NPI:1861197436
Name:CANTWELL, LISA (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CANTWELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 PURGASON RD
Mailing Address - Street 2:
Mailing Address - City:MOHAWK
Mailing Address - State:TN
Mailing Address - Zip Code:37810-5551
Mailing Address - Country:US
Mailing Address - Phone:423-231-4544
Mailing Address - Fax:
Practice Address - Street 1:1250 TENNOVA MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-3120
Practice Address - Country:US
Practice Address - Phone:865-895-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist