=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861197436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA CANTWELL RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2023
-----------------------------------------------------
Last Update Date | 04/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 TENNOVA MEDICAL WAY
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37909-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-895-6072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 PURGASON RD
-----------------------------------------------------
City | MOHAWK
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37810-5551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-231-4544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 22686
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------