MEDICARE: MRS. LISA G MCDONALD RPH, CDM

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	017231	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	017231	OTHER	GA	STATE PHARMACIST'S LICENS

General Provider Information

NPI Number	:	1659436053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA G MCDONALD RPH, CDM

Provider Business Mailing Address
First Line	:	528 SPARTA RD
Second Line	:
City	:	SANDERSVILLE
State	:	GA
Zip	:	31082-1859
Country	:	US
Telephone Number	:	478-552-6114
Fax Number	:	478-552-6119

Provider Business Practice Location Address
First Line	:	528 SPARTA RD
Second Line	:
City	:	SANDERSVILLE
State	:	GA
Zip	:	31082-1859
Country	:	US
Telephone Number	:	478-552-6114
Fax Number	:	478-552-6119

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/08/2007

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