Provider Demographics
NPI:1326433459
Name:LILJEGREN, RANDALL (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:
Last Name:LILJEGREN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1471
Mailing Address - Country:US
Mailing Address - Phone:715-258-9000
Mailing Address - Fax:715-258-4119
Practice Address - Street 1:825 W FULTON ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1471
Practice Address - Country:US
Practice Address - Phone:715-258-9000
Practice Address - Fax:715-258-4119
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11656-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist