Provider Demographics
NPI:1679062566
Name:MAYO, LISA C (DPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:MAYO
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 EMPORIUM DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6004
Mailing Address - Country:US
Mailing Address - Phone:731-668-1277
Mailing Address - Fax:
Practice Address - Street 1:2196 EMPORIUM DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6004
Practice Address - Country:US
Practice Address - Phone:731-668-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-06
Last Update Date:2018-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist