MEDICARE: LILLY MANDUKU

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	42289	TX

General Provider Information

NPI Number	:	1336741990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLY MANDUKU

Provider Business Mailing Address
First Line	:	6360 LAKE WORTH BLVD
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3604
Country	:	US
Telephone Number	:	817-237-1118
Fax Number	:	817-237-1119

Provider Business Practice Location Address
First Line	:	6360 LAKE WORTH BLVD
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3604
Country	:	US
Telephone Number	:	817-237-1118
Fax Number	:

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

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	11/09/2020

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Directions to “ LILLY MANDUKU ” Practice Location

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