Provider Demographics
NPI:1184228405
Name:TACKAGE, ALICIA LEE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LEE
Last Name:TACKAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1795 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-1765
Mailing Address - Country:US
Mailing Address - Phone:740-335-6162
Mailing Address - Fax:740-335-1618
Practice Address - Street 1:1795 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1765
Practice Address - Country:US
Practice Address - Phone:740-335-6162
Practice Address - Fax:740-335-1618
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03221401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist