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NPI Code Detail

MEDICARE: JACOB THOMAS LILLETVEDT PHARMACIST

MEDICARE: JACOB THOMAS LILLETVEDT PHARMACIST
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
1183500000XPharmacistPHA-PHA-LIC-55429MT

General Provider Information

NPI Number : 1013574441
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB THOMAS LILLETVEDT PHARMACIST
Provider Business Mailing Address
First Line : 315 CHARLES ST APT 28
Second Line :
City : MILES CITY
State : MT
Zip : 59301-4158
Country : US
Telephone Number : 406-262-3515
Fax Number :
Provider Business Practice Location Address
First Line : 519 S HAYNES AVE
Second Line :
City : MILES CITY
State : MT
Zip : 59301-4768
Country : US
Telephone Number : 406-232-4627
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/21/2019
Last Update Date : 05/21/2019

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