MEDICARE: DR. THOMAS EDWARD LACKNER PHARMD

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	1835P1200X	Pharmacotherapy Pharmacist	1131677	MN

General Provider Information

NPI Number	:	1215934344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS EDWARD LACKNER PHARMD

Provider Business Mailing Address
First Line	:	1372 138TH LN NW
Second Line	:
City	:	ANDOVER
State	:	MN
Zip	:	55304-4095
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1372 138TH LN NW
Second Line	:
City	:	ANDOVER
State	:	MN
Zip	:	55304-4095
Country	:	US
Telephone Number	:	763-755-3662
Fax Number	:

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

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	07/08/2007

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