Healthcare Provider Details

I. General information

NPI: 1467631226
Provider Name (Legal Business Name): LAKISHA G ROE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 MAGNOLIA CIR BLDG 1465
TYNDALL AFB FL
32403-5604
US

IV. Provider business mailing address

340 MAGNOLIA CIR BLDG 1465
TYNDALL AFB FL
32403-5604
US

V. Phone/Fax

Practice location:
  • Phone: 850-583-2778
  • Fax:
Mailing address:
  • Phone: 850-583-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12680
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: