Provider Demographics
NPI:1396020954
Name:LICKLITER, MOLLY E (PHARMD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:E
Last Name:LICKLITER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2102
Mailing Address - Country:US
Mailing Address - Phone:317-228-0419
Mailing Address - Fax:317-228-0292
Practice Address - Street 1:1330 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2102
Practice Address - Country:US
Practice Address - Phone:317-228-0419
Practice Address - Fax:317-228-0292
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023531A183500000X
IA20837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist