Healthcare Provider Details

I. General information

NPI: 1700868429
Provider Name (Legal Business Name): LISA OH LAUREL PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: LISA EUN SOOK OH PHARM D

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LLEWELLYN AVE
FORT MEADE MD
20755-5800
US

IV. Provider business mailing address

2480 LLEWELLYN AVE
FORT MEADE MD
20755-5800
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-8611
  • Fax: 301-677-8456
Mailing address:
  • Phone: 301-677-8611
  • Fax: 301-677-8456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14245
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: