Provider Demographics
NPI:1255487997
Name:BACKLUND, LORI A (RPH)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:BACKLUND
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 1:13727 SHAVANO WIND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5824
Mailing Address - Country:US
Mailing Address - Phone:214-250-9095
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-5413
Practice Address - Fax:210-292-1216
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4777183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58230Medicaid
NM3207215OtherNCPDP PHARMACY ID
NM58230Medicaid