Healthcare Provider Details

I. General information

NPI: 1063406833
Provider Name (Legal Business Name): LISA M GARDNER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N 1ST ST
FLIPPIN AR
72634-8613
US

IV. Provider business mailing address

PO BOX 1390
FLIPPIN AR
72634-1390
US

V. Phone/Fax

Practice location:
  • Phone: 501-313-1148
  • Fax:
Mailing address:
  • Phone: 870-493-7367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number08467
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: