Provider Demographics
NPI:1366771420
Name:BUCKLEW, LISA D (PHARMACY TECHNICIAN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:BUCKLEW
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1200
Mailing Address - Country:US
Mailing Address - Phone:218-834-7202
Mailing Address - Fax:218-834-9531
Practice Address - Street 1:1010 4TH ST
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1200
Practice Address - Country:US
Practice Address - Phone:218-834-7202
Practice Address - Fax:218-834-9531
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN720724183700000X
MN4901-0701-0056-480183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician