Healthcare Provider Details

I. General information

NPI: 1487800090
Provider Name (Legal Business Name): LAKEYA M TILLMAN PHARM. D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-3100
  • Fax: 414-219-6188
Mailing address:
  • Phone: 414-219-3100
  • Fax: 414-219-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14703-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: