Provider Demographics
NPI:1013574441
Name:LILLETVEDT, JACOB THOMAS (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:LILLETVEDT
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 CHARLES ST APT 28
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-4158
Mailing Address - Country:US
Mailing Address - Phone:406-262-3515
Mailing Address - Fax:
Practice Address - Street 1:519 S HAYNES AVE
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-4768
Practice Address - Country:US
Practice Address - Phone:406-232-4627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-55429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist