Provider Demographics
NPI:1255618823
Name:MARTINEZ, LISA KIEP (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KIEP
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19803 KISHWAUKEE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-8605
Mailing Address - Country:US
Mailing Address - Phone:815-355-4294
Mailing Address - Fax:
Practice Address - Street 1:395 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3258
Practice Address - Country:US
Practice Address - Phone:815-943-4376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038576183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist