Healthcare Provider Details

I. General information

NPI: 1104074509
Provider Name (Legal Business Name): LISA RENE YOUNG PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ANNE RENE PHARM.D.

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE DEPARTMENT OF PHARMACY (119)
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

420 N JAMES RD DEPT OF
COLUMBUS OH
43219-1834
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-7949
  • Fax: 312-569-6185
Mailing address:
  • Phone: 614-257-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.293032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: