MEDICARE: MRS. LISA R ANDERSON R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051-038120	IL

General Provider Information

NPI Number	:	1376992917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA R ANDERSON R.PH.

Provider Business Mailing Address
First Line	:	1501 S LAKE ST
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 S LAKE ST
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4258
Country	:	US
Telephone Number	:	847-566-0991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2016
Last Update Date	:	06/05/2016

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