Provider Demographics
NPI:1467631226
Name:ROE, LAKISHA G (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:G
Last Name:ROE
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 1:1405 CHILDRESS ST
Mailing Address - Street 2:
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-4305
Mailing Address - Country:US
Mailing Address - Phone:843-452-0089
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3430
Practice Address - Country:US
Practice Address - Phone:940-676-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCI-4779390200000X
SC12680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467631226OtherUSAF