Provider Demographics
NPI:1083115984
Name:LACEY, LORA (RPH)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:LACEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 MACARTHUR BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2916
Mailing Address - Country:US
Mailing Address - Phone:219-836-2480
Mailing Address - Fax:219-836-0560
Practice Address - Street 1:801 MACARTHUR BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2916
Practice Address - Country:US
Practice Address - Phone:219-836-2480
Practice Address - Fax:219-836-0560
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020401A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist