Healthcare Provider Details

I. General information

NPI: 1619814696
Provider Name (Legal Business Name): LISA RENEE KOSELKE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

4916 SUMMER AVE NE
ALBUQUERQUE NM
87110-6334
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2033
  • Fax:
Mailing address:
  • Phone: 847-401-7519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007531
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: